
Book JIt- 



CoppghtN". 



COPYRIGHT DEPOSIT. 



GOLDEN RULES 
OF GYNECOLOGY 



OOLDEN RULE SERIES 



GOLDEN RULES 

OF 

GYNECOLOGY 



APHORISMS, OBSERVATIONS, AND PRECEPTS ON THE 

PROPER DIAGNOSIS AND TREATMENT OF 

DISEASES OF WOMEN 



BY 
GEORGE B. NORBERG, M. D. 



PROFESSOR OF DISEASES OF WOMEN AND CLINICAL GYNECOLOGY, UNIVERSITY 

MEDICAL college; GYNECOLOGIST KANSAS CITY GENERAX- 

hospital; FELLOW AND EX-PRESIDENT KANSAS 

CITY ACADEMY OF MEDICINE 



ST. LOUIS 

C. V. MOSBY COMPANY 

1913 






Copyright, 1913, by C. V. Mosby Company 



Press of 

C. V. Mosby Company 

St. Louis 



©CI.A343531 



PEEFACE. 

The purpose of this volume is to give its readers 
those methods of gynecologic diagnosis and treat- 
ment, the observance of which is known to produce 
the best results. 

The demands made upon the time of the busy gen- 
eral practitioner are so many and so varied that it is 
necessary for him to eliminate from his reading 
lengthy dissertations that repeat what has been said 
over and over again, and that often leave obscure 
the ideas that they intend to convey. 

A great many subjects are given considerable 
space in textbooks on gynecology, which really be- 
long under general surgery. No attempt has been 
made to cover these .subjects. 

It has been a constant effort to make short, em- 
phatic, and convincing statements that may prove 
to be of practical value. 

The literature on gynecology has been thoroughly 
searched, and what has seemed to be the best meth- 
ods of procedure have been incorporated in this lit- 
tle book. 

In my work on this volume this fact has been in- 
delibly impressed upon me: ^'How much is written, 
how little really said.'^ The greatest task is how 

7 



8 PEEFACE. 

to condense so that every statement means some- 
thing — ^'To pnt the nail in the right place and to 
drive it home." How well I have succeeded must 
be left to my readers. I trust, however, that they 
will be as much benefited in reading it as I have been 
in the preparation of the same. 

I am indebted to Dr. Henry A. Cables for his assist- 
ance in going through the gynecologic literature, I 
am deeply indebted to the publishers for their assist- 
ance and patient indulgence. 

Geo. B. Noeberg. 

Eialto Bldg., 

Kansas City, Mo. 



CONTENTS. 

PAGE 

Introduction '...,.... 11-13 

CHAPTEE I. 

GENERAL CONSIDERATIONS. 
Diagnosis — Local Treatment — Constipation 15-30 

CHAPTER II. 

DISEASES OF THE VULVA. 

Vulvitis — Bartholinitis — Cysts of the Vulvovaginal Glands 

— Pruritus Vulvae — Kraurosis Vulvae — Elephantiasis 
Vulvae — Varicose Veins — Hydrocele of the Labium 
Majus — Inguinolabial Hernia — Chancroids — Chancre 

— Verrucas — Adliesions of the Clitoris — Adhesions of 
the Labia — Herpes — ■ Eczema — Thrush — Simple Der- 
matitis — Erysipelas — Vaginismus 31-77 

CHAPTER III. 

DISEASES OF THE VAGINA. 

Acquired Stenosis and Atresia — Cystocele and Rectocele — 
Hernia — Vaginitis — Granular Vaginitis — Senile 
Vaginitis — Cysts — Cancer of the Vagina — Gonorrhea 78-111 

CHAPTER IV. 

DISEASES OF THE UTERUS. 

Posterior Displacement — Prolapse of the Uterus — Inver- 
sion of the Uterus — Fibromata — Cancer of the Uterus 

9 



10 CONTENTS. 

PAGE 

— Sarcoma — Inflammation of the Uterus — Metritis — 
Endometritis — Endocervicitis — Subinvolution of the 
Uterus — Superinvolution — Laceration of the Cervix — 
Hypertrophy of the Cervix — Cervical Pohq i — Ac- 
quired Atresia of the Cervix — Acquired Stenosis of the 
Cervix — Chorioepithelioma 112-174 

CHAPTER V. 

DISEASES OF THE TUBES AND OVARIES, 

Salpingitis — Diseases of the Ovaries — Chronic Ovaritis — 
Prolapse of the Ovaries — Solid Tumors of the Ovaries 

— Ovarian Cysts — Ectopic Gestation 175-196 

CHAPTER VIo 

MENSTRUATION AND ITS DISORDERS. 

Puberty — Menstruation — Ovulation — Menopause — 
Precocious Menstruation — Delayed Menstruation — 
Amenorrhea — Menorrhagia and Metrorrhagia — Dys- 
menorrhea 197-212 

CHAPTER VII. 

DISEASES OF THE URETHRA. 

Urethritis — Stricture — Vesicourethral Fissure — Prolapse 

— Urethrocele — Caruncle 213-222 

CHAPTER VIII. 

DISEASES OF THE BLADDER. 
Cystitis — Vesical Calculus ...,....,. 223-227 



'CI,A343531 



INTEODUCTION. 

Eemember that one of the most important prin- 
ciples in gynecologic practice is every-day asepsis. 

Cleanliness of mind is as necessary as cleanliness 
of body. 

Eemember that, unless your patient has a good 
reason for an examination being postponed, it is far 
better to lose the prospective patient than to pre- 
scribe symptomatically. She will return for her ex- 
amination after a few weeks of internal medication 
by some other physician. 

Eemember that there are exceptions to this rule; 
unless the gravity of the case demands it, it is not 
wise to examine young girls or .single women — if it 
should become necessary, and she is a modest, bash- 
ful person, her nervous system can be maintained in 
a better condition by administering an anesthetic 
for such an examination. Moreover the examina- 
tion can be made then with perfect satisfaction, on 
account of the complete relaxation and freedom from 
pain. 

Eemember that pelvic examinations should never 
be undertaken with a woman lying recumbent in 
bed. Knowledge thus gained is usually very unre- 
liable. One frequently is obliged to use a bed in- 
stead of an examining-table ; but the patient should 

11 



12 INTKODUCTION. 

be placed across the bed with the hips on or near the 
edge and the knees slightly flexed. The annoyance 
from the sinking-down of the hips can be obviated by 
flipping two boards from a dining-room table nnder 
the mattress. 

Tables are far superior to chairs for office work. 

Much annoyance can be spared a physician if he 
would have a relative or friend accompany the pa- 
tient to his office for examination or treatment. 

Examine as many women as your opportunity af- 
fords, thereby becoming familiar with the normal 
and the abnormal. It requires much practice to 
educate the fingers to a keen sense of touch. The 
examining finger alone gives one only an idea of the 
condition of the vagina, whether the bladder is sag- 
ging (cystocele), or the rectum bulging (rectocele), 
and a general idea of the condition of the cervix. 
It requires the combined examination — vaginoab- 
dominal, the rectoabdominal — to ascertain with any 
degree of accuracy the true condition in the pelvis. 

The speculum is a very useful adjunct where it is 
desired to bring into view the cervix or the sur- 
rounding vaginal wall, but one should never make a 
diagnosis by the use of the speculum alone — the 
speculum examination should usually follow the bi- 
manual examination. 

One must learn to judge his patient; don't be 
vacillating in your advice or opinion; be sure you 
are right, and stick to it. In such a case informa- 
tion and advice carry confidence and conviction di- 



INTEODUCTION. 13 

rectly to tlie patient; while with the contrary she is 
soon filled with distrust. 

Your conscience should not permit of wrong-doing 
for pay; there is enough legitimate work for all. 



GOLDEN RULES OF GYNE- 
COLOGY 

CHAPTER I. 
GENERAL CONSIDERATIONS. 

DIAGNOSIS. 

General. — Learn to be observing; this comes with 
experience, of course, but is much more easily ac- 
quired by some than others. 

Often many things are suggested to the experi- 
enced and observing physician by the first glance 
at his patient. A woman, near the age of fifty, who 
is anemic, with skin dry and waxy, suggests carci- 
noma of the uterus or of the mammary gland; one 
who is thin, with a pinched expression, large abdo- 
men, and who walks carefully and with .some diffi- 
culty, may suggest ovarian cystoma. A woman in 
the middle period of life, plump, with a large ab- 
domen, but with rosy cheeks, who walks with a 
strong, steady step, suggests normal pregnancy. 

Remember that diseases of the. middle period of 
life are more frequently inflammatory, and due to 
accidents of child-birth, abortions, and infections, 

15 



16 GOLDEN RULES OF GYNECOLOGY. 

while in the earlier life of the female the disorder.s 
of the menstrual functions are the ones with which 
we have to deal. These are mere suggestions at the 
beginning of the examination of our patient, but 
they will be found to be of great help if properly 
regarded. 

Always keep a full history of every patient, with 
diagnosis, and treatment, whether medical or surgi- 
cal. It is very embarrassing to have a patient return 
in two or three years and refer to her former sick- 
ness and treatment, which, of course, is entirely for- 
gotten. If an accurate history and record are kept, 
one can refer to them, and the case at hand will be 
fresh in one's memory. 

Don't bother the patient and waste your own time 
with a number of unnecessary questions; remember 
that the history of remote ancestors is seldom of vital 
importance in gynecologic practice. As a general 
rule, it is best to note down the name, address, age, 
height, weight, whether married or single, etc., and 
then allow the patient to tell the nature of her symp- 
toms and sickness. This soon brings the physician 
to a definite plan of procedure, when he can proceed 
with a .systematic inquiry and note down at the same 
time points of interest. 

(1) Menstruation. — At what age did it begin; reg- 
ular or irregular; how many days does it last; nor- 
mal, scanty, or profuse in amount; is it painful; if 
so, what relation does it have to flow 1 If the patient 
has reached the menopause, inquire at what age; 



GENERAL CONSIDEEATIONS. 17 

whether it has ever returned ; and any questions per- 
tinent to the case. 

(2) The number of children; whether miscar- 
riages or abortions; were any of them of unusual 
.severity; were instruments used; was the convales- 
cence delayed beyond the usual time with any of 
them; and if so, why? 

(3) Inquire if she has leucorrhea; whether pro- 
fuse; color; odor. Is it present during entire inter- 
menstrual period; does it cause itching or burning? 

(4) Is there irritation of the bladder causing fre- 
quent micturition; or is there difficulty in urinating? 

(5) Inquire regarding the bowels; whether consti- 
pated or not. 

(6) Is there pain in the pelvis; if so, is it con- 
stant; does it radiate from hips down thighs and to 
calves of legs? 

(7) Is there backache; if so, where located? 

(8) Is there headache; if so, where? 

Physical. — Remember that it is not safe to omit a 
thorough examination of the chest and abdomen be- 
fore attempting to make a diagnosis of a pelvic 
lesion. This is particularly true if an operation is 
necessary for relief ; although there are now but few 
patients that cannot take an anesthetic, patients feel 
better satisfied if the physician examines them and 
assures them that they can take it safely. 

Remember that the abdomen should be carefully 
examined, and finally the pelvic organs. Uterine 
fibroids, large cysts- of the ovaries, and the gravid 



18 GOLDEN EULES OF GYNECOLOGY, 

uterus can be palpated above the pelvis, but this 
should usually be accompanied by the vaginoab- 
dominal palpation. This means the index finger of 
one hand in the vagina, and the other hand pressing 
down above the pubis and over the abdomen. 

The rectoabdpminal examination is often useful 
(index finger of one hand in rectum, the other hand 
above pubis) in examining for tumors and exudaites 
low in pelvis. 

Do not attempt an examination if the rectum is 
filled with fecal matter or the bladder full of urine; 
it may change the position of the pelvic organs very 
materially and interfere with a correct diagnosis. 

Don't be in too great haste to give an opinion in 
a chronic case, where the patient has a fat abdomen 
and where the examination is difficult — it is better to 
have her come back a second or third time. 

Don't attempt to examine young girls or unmar- 
ried women, especially when it is against their 
wishes, without an anesthetic. 

Instrumental. — Now remember that preceding the 
use of a vaginal .speculum or perineal retractor the 
external genitals are to be inspected. These are 
usually taken in at a glance without much unneces- 
sary handling of the parts. Note if there is any 
discharge; its color and consistency; whether it 
causes excoriation of the parts ; whether there are 
chancre, chancroid, venereal warts, or other dis- 
eases of the external genitals; as adhesions and 
irritations of the external meatus, hymen, or carun- 



GENERAL CONSIDEEATIONS. 19 

cula myrtif ormis ; laceration of perineum, with cys- 
tocele and rectocele; hemorrhoids, or anal fissure or 
fistula. 

Eemember that the ordinary bivalve speculum, 
with the patient in the dorsal position, is sufficient 
for examination of the cervix uteri. Inspect the 
cervix; notice if it is swollen or lacerated; whether 
the lateral walls are white and hard with scar tis- 
sue; whether it is studded with small white cysts, 
due to the plugging up of the Nabothian glands. 
Notice the amount and character of discharge, ulcer- 
ations, or evidence of malignant disease, etc. 

Remember that the normal color of the cervix is 
pink (it has a bluish hue in pregnancy), it is smooth 
and conical in shape; inflammation causes it to be- 
come large, red, and rough. It should also be noted 
whether the external os is of the pinhead variety or 
whether it is sufficiently large. 

Eemember that the perineal retractor, with the pa- 
tient in either the lateral or semiprone po.sition, is 
useful where it is desired to pull the cervix down 
within easy grasp or exposure; this position is es- 
pecially useful in removing stitches from the cervix 
or in removing a polypus from the canal of the cer- 
vix uteri. 

Don't make a practice of using a sound in the 
uterus at overy opportunity; this practice should be 
condemned except in very exceptional cases, for the 
sake of clearing up a diagnosis or where some intra- 
uterine treatment is especially indicated, and then 



20 GOLDEN RULES OF GYNECOLOGY. 

with the strictest aseptic precautions; much harm 
has been done by the promiscuous use of intrauterine 
instrumentation. 

Microscopical and Chemical. — Don't fail to make 
a thorough examination of the urinary organs and 
their excretions. The modern physician is so skilled 
that he can easily make a thorough chemical and 
microscopic examination of the urine. Cystoscopy 
and ureteral catherization are so common and are 
accomplished with so little difficulty nowadays, that 
diseases of the kidneys, ureters, and bladder can be 
quite accurately diagnosed. 

Don't fail to make a microscopic examination of 
the vaginal and uterine discharges, where it is indi- 
cated. 

Don't make a positive diagnosis of cancer of the 
uterus (except in advanced cases) without a micro- 
scopic examination. 

Don't fail to resort to the microscope in case of 
any ulceration or any suspicious appearance of the 
cervix. It is sometimes necessary to use the curette 
to get a specimen from the fundus or high in the 
cervix for microscopic examination. 

Don't pass over a suspicious-looking cervix, and 
say that it is not cancer because the patient is too 
young — one is scarcely exempt from it at any age ; it 
is not rare in the twenties. 

It is sometimes necessary to make an exploratory 
incision to clear up a doubtful diagno.sis ; when this 
becomes necessary, the surgeon should be ready to 



GEN"EKAL CONSIDEKATIONS. 21 

meet any condition that presents itself and to do 
a finished operation. 

Don't fail to make a blood examination when- 
ever it is indicated for an index, or to help to clear 
up a doubtful diagnosis. 

LOCAL TREATMENT. 

While there is much to be accomplished by local 
treatment in gynecologic cases, yet in no class of 
diseases, perhaps, has local treatment been miscar- 
ried farther than for ailments peculiar to women. 
It is doubtful if there is any inflammatory disease 
(at least chronic) of the pelvic organs of a woman 
that cannot be relieved temporarily by the use of 
tampons of glycerin and ichthyol, or borogiycerid 
and glycerin, with daily hot douches. Remember 
that this practice is perfectly proper and .should be 
highly endorsed when it is done for temporary re- 
lief, and when it is so understood by the patient; 
but when undertaken as a curative measure in all 
the distorted conditions of the pelvic organs, with 
adhesions and even pus collections, too much can- 
not be said against it; and if one will only famil- 
iarize himself with the anatomy of these parts, as 
well as acquire an accurate knowledge of the path- 
ology of pelvic disease, he will need no further proof 
to convince him of the exact limitations of local 
treatment. 

The efficiency of rest in bed, the hot douche, and 
hot fomentations in acute inflammatory disease of 



22 GOLDEN" RULES OF GYNECOLOGY. 

the pelvic organs cannot be gainsaid by anyone wbo 
has tried them intelligently; bnt they are seldom 
so used, except in the hands of a trained nurse. 

Effect of the Hot Douche and Applications. — In a 
great measure this acts in the same manner as Bier's 
hyperemic treatment — by its local effect it stimu- 
lates the walls of the relaxed blood-vessels, causing 
a contraction. If this is continued for a long time 
and frequently, the circulation will improve ; and in- 
stead of the relaxed vessels, with stasis and edema 
of the surrounding tissues from exudation, the ves- 
sels contract, circulation is improved, the exudate is 
absorbed, and the swelling and pain are relieved. 

Eemember that if this line of treatment is insti- 
tuted early it may prevent adhesions, abscess for- 
mation, and general deformity of the pelvic organs. 

Now remember that douches for this purpose 
should be taken lying down (either using a douche 
pan or getting into the bathtub). It is not neces- 
sary to have a swift stream of water; hence the ir- 
rigator or douche bag need not hang high. Enough 
water (at about 110° F.) should be used to make the 
douche last for ten or fifteen minutes. 

Eemember that the virtue of this treatment lies 
in keeping the heat and moisture in contact with 
the inflamed tissues a long time. This should be 
repeated at intervals of every two hours, day and 
night. If there is any odor to the discharges, a 
teaspoonful of formaldehyd, 40 per cent, can be 
added. Any other medicinal agent may be used 



OENEKAL CONSIDEBATIONS. 23 

that miglit be suggested for the particular case. 

Eemember that the hot fomentatious should be 
changed as frequently as they cool — every five to 
ten minutes. In hospital practice (and it can be 
done in private practice), a bag is made with a stick 
sewed in at each end; the flannel cloth that is used 
for the application is placed in this bag, and the 
whole placed in the vessel of boiling water. This 
is wrung out by use of the sticks, the whole carried 
to the bedside of the patient, when the flannel is 
removed from the bag (steaming hot), and placed 
on the patient's abdomen as warm as it can be tol- 
erated, and the cooled application is placed into the 
bag and pan of hot water. This is repeated back 
and forth, and it requires about all of one nurse's 
time to give the douches, and use the hot applica- 
tions properly. It is wonderful, however, how 
quickly and completely this plan of treatment gives 
relief; the patient who has been in the throes of pain 
in twelve to twenty-four hours begins to heave sighs 
of relief, the pulse becomes softer and slower, and 
the temperature drops. 

Eemember that the bowels should be thoroughly 
evacuated daily by the use of salines, cathartic 
waters, or enemata. 

Remember that in subacute or chronic diseases of 
the pelvic organs tamponade with the various mix- 
tures of glycerin serves splendidly for temporary 
relief. Clinical patients are living examples and 
prove beyond dispute just how far this line of treat- 



24 GOLDEN KULES OF GYNECOLOGY. 

ment is meritorious. They are a class of people 
whose time is required every day for the support of 
themselves and their families; they cannot lie 
around as invalids, nor have they time to go to a 
hospital for a .surgical operation. They come to our 
clinics with the gravest pelvic disease, scarcely able 
to walk, and if they were women of a higher plane 
in life, they would be confined in bed. Something 
must be done for them; so they are given a tampon 
of glycerin and ichthyol, 10 per cent, and instructed 
in the art of taking douches. After three or four 
visits they return smiling and say that they feel 
much better. After ten or twelve treatments they 
disappear, only to return with a relapse in a few 
weeks or months. Large numbers continue in this 
way for years, and indefinitely. 

Eemember that, while the value of the tampon to 
some extent is derived from the medicinal sub- 
stances that it carries to the cervix, and as a support 
to the uterus in some cases, yet the greatest benefit 
comes from the glycerin mixtures, on account of 
their hygroscopic properties. Do not use cotton 
tampons; they become too hard and cause pain. 
Lamb's wool, with a piece of string tied to it, is a 
splendid tampon. A very convenient tampon is 
made by cutting plain gauze four or five inches wide 
by two feet in length. Saturate about one half of it, 
and pack around the cervix as desired through an 
ordinary bivalve speculum, leaving about one inch 
outside of vagina so that patient can readily pull it 



GENEEAL CONSIDERATIOl^S. 25 

out wlien it lias served its usefulness. In withdraw- 
ing the speculum, gentle pressure must be made 
against the tampon with the dressing forceps, so 
that it may not become dislodged. A tampon .should 
be left in from twelve to twenty-four hours. 

Hemorrhage. — Remember that tampons are often 
useful in checking uterine hemorrhage. By the use 
of a bivalve speculum or a perineal retractor small 
pieces of cotton, wrung from warm water, are 
packed well up around the cervix, finally filling the 
vagina. The cotton might be wrung from a boric 
acid or a weak formalin solution for the antiseptic 
effect, or a weak solution of adrenalin may be used 
for its astringent properties. If the hemorrhage is 
very great, this entire pack may be forced out by 
the blood-clots and fluid blood coming from the 
uterus. 

Eemember that, if the cervix is or can be suffi- 
ciently dilated, strips of gauze, wrung from some 
mild astringent solution, and packed directly into 
the cavity of the uterus, are effective when vaginal 
packing fails. 

Remember that in ulceration or erosion of the cer- 
vix local treatment must be instituted, but we must 
not mistake the hypertrophied everted cervical mu- 
cous membrane of a lacerated cervix for ulceration 
and erosion. 

Remember that retention cysts of the Nabothian 
glands are relieved by puncture, followed by tam- 
ponade, hot douches, etc. 



26 GOLDEN KULES OF GYNECOLOGY. 

Infection, particularly gonorrheal, is met by local 
treatment. In such a case, remember that rest in 
bed and vigorous treatment to prevent its spread 
beyond the vagina are demanded to save her from 
being completely ruined. 

Local treatment is necessary, effective, and often 
entirely sufficient in many of the diseases of the 
vulva or external genitals. 

Intrauterine. — Don't get into the habit of using 
intrauterine treatments indiscriminately. Women 
as a whole would have been much better off had this 
plan of treatment never been instituted. When it 
does become necessary, use it under the strictest 
aseptic precautions. It may be of benefit in cases 
of acute endometritis without infection, when a few 
applications of tincture of iodin may be applied to 
the endometrium. 

Eemember that the cervix should be well dilated 
and the applications made two or three days apart; 
if three or four treatments do not give the effect 
desired, it is better to desist, and let the patient rest 
from treatment for a time. 

It is a question whether or not the benefit derived 
in these cases comes from the astringent applica- 
tion or from the dilatation of the cervix alone, thus 
establishing better drainage from the uterine cavity. 

Eemember that it is necessary to curette and wash 
out debris from the uterus, following miscarriage or 
abortion; but remember that this can be done more 
thoroughly and safer under a general anesthetic. 



GENEBAL CONSIDEEATIONS. 27 

Operations of this magnitude should be done in a 
hospital; don't undertake them in the office. 

It is permissible to use a uterine sound in cases 
of uterine fibroids (posterior) or prolapse, in order 
to clear up an uncertain diagnosis, but these cases 
are rare. Now reason, and see if it does not appear 
quite doubtful whether argyrol, protargol, or any 
of these antiseptics has any beneficial effect what- 
soever in destroying pathogenic micro-organisms 
within the cavity of the uterus; the issue almost en- 
tirely depends on the antitoxic ability of the blood, 
with its leucocytes. Now, if it were po.ssible to say 
that the infection was limited to the surface of the 
endometrium, it might do some good, but even then, 
we might bruise the otherwise intact endometrium, 
which was furnishing splendid resistance, and open 
up new portals for the entrance of infection to the 
deeper structures. 

CONSTIPATION. 

Eemember that most women are constipated and 
that assistance in a general way (diet, exercise, etc.) 
may save her from the necessity of taking daily 
cathartics. 

Eemember that the ill effects of constipation are 
not only in the failure to remove the residue from 
the intestinal tract and its discomforts; its evil ef- 
fects reach the whole economy. Wliile the seden- 
tary habits of a woman are no doubt justly blamed 
for a part of her constipation, and no doubt also. 



28 GOLDEN KULES OP GYNECOLOGY. 

may be blamed for the chronic disorders of the 
stomach, intestines, liver, and kidneys, yet, on the 
other hand, there are other anatomical and 
physiological reasons. 

Eemember that the pelvic organs become con- 
gested and engorged at every menstrual period. 
Lacerations of the perineum allow displacement, and 
interference with the function of the rectum. 
Uterine prolapse and displacements, tumors of the 
uterus and ovaries in a mechanical way produce con- 
stipation, and moreover, it is not always so con- 
venient for a woman to regard and attend the calls 
of Nature as it is for a man. However she should 
be taught from childhood that it is extremely neces- 
sary to obey Nature promptly in her demands, and 
to render assistance by forming regular habits — to 
go to stool regularly, just as she has regular hours 
for meals. 

A woman who does her own housework or looks 
after her own children .should not be accused of 
sedentary habits. However, when she is guilty of 
leading a sedentary life, it must be overcome, and 
no doubt, in such a woman it can best be accom- 
plished by ordering gymnastics, massage, or some 
form of exercise that is combined with pleasure. 

Now remember that women do not drink enough 
water. Water not only furnishes the proper fluid 
to the body, but taken in proper quantities and at 
proper times, cleanses the stomach of mucus, pro- 
motes peristalsis, increases perspiration and the 



GENERAL CONSIDERATIONS. 29 

quantity of both solid and watery constituents of the 
urine, aiding the excretion of carbonic acid and ab- 
.sorption of oxygen; thus, all the tissues in the body 
are relieved of salts and waste material, and the 
tendency to calcareous degeneration of blood-vessels 
is lessened. 

To say that distilled or boiled water is dead and 
has no virtue is a mistake. Boiled water contains 
but few salts and distilled water no salts, and there- 
fore they have greater absorbing power when filter- 
ing through the system. While it is also free from 
pathogenic micro-organisms, the food that we eat 
furnishes enough of the earthy salts to our system, 
so that they do not have to be taken in the water we 
drink. 

To get a woman to drink enough water daily, the 
amount and time must be specified until she has ac- 
quired the. habit, so to speak. A woman who is in 
normal health should drink from one and a half to 
two quarts of water daily. A good practice, I be- 
lieve, is to have her take a bottle or pitcher of water 
to her bedroom at night; advise her to drink one or 
two glasses full while she is dressing in the morn- 
ing; this washes the mucus from her stomach, im- 
proves the appetite for breakfast, and aids the peris- 
taltic action of the bowels. 

Large quantities of water should not be taken dur- 
ing meals, as it dilutes the digestive fluids and pre- 
disposes to indigestion. The drinking of several 
glasses of iced tea with meals should be condemned. 



30 GOLDEN RULES OF GYNECOLOGY. 

A glass or two of water should be drunk between 
meals, and the same amount taken between the even- 
ing meal and bedtime. The temperature of the 
water need only be that of ordinarily cool drinking 
water. 

If the case is obstinate, a one-fourth to one-third 
teaspoonful of common table salt added to the water 
taken before breakfast acts almost as well as a saline 
cathartic. Fruit of some kind should be eaten be- 
fore breakfast. 

In very obstinate cases a tablespoonful of olive oil 
taken with each meal helps very materially. Of 
course, in the cases that do not yield to this line of 
treatment, it may become necessary to divulse the 
spincter ani under an anesthetic, and to resort to 
the various aperient waters or mild cathartics at 
tim.es, until we have been able to correct the trouble 
entirely. 



CHAPTER II 

DISEASES OF THE VULVA„ 

VULVITIS. 

Remember that there are three varieties: viz., the 
simple, the follicular, and the gonorrheal. 

Remember that- simple vulvitis found in adults is 
due to a lack of cleanliness, and the colon bacillus 
and the skin cocci are found. 

Be careful to eliminate a redness and swelling due 
to trauma caused by riding, cycling, etc. 

Remember that in addition to the redness and 
swelling there will be found an increase in the 
mucous discharges, and mucopus, red dots marking 
the site of the orifices of the tubular glands; also, 
there will be itching of the parts and scalding dur- 
ing urination. 

Remember that in women who have diabetes and 
an ammoniacal urine the sebaceous glands become 
inflamed and discharge pus, or the mouth of the 
glands becomes plugged, when there will be pro- 
duced an acne-like pustule- 
Remember that a vulvitis with intense pruritus 
with dry, parchment-like skin and mucous mem- 
brane calls for an examination of the urine for 
sugar. 

31 



32 GOLDEN KULES OF GYNECOLOGY. 

Remember that the gonorrheal vulvitis is much 
more common in the cities and large towns. 

But remember that the history that can be elicited 
from the patient makes the task of differentiation 
more simple. Even if the patient is unwilling to 
give the desired information the objective symptoms 
will be of sufficient 'Hell-tale" character to get her 
to admit the possibility of an infection. 

Remember that on inspection the urethral orifice 
is puffy and red, and by pressure pus may be forced 
out ; the prepuce and clitoris are edematous, and the 
engorgement of the erectile tissue causes a semi- 
erection of the clitoris; the ducts of Bartholin's 
glands are swollen and discharge pus, and the entire 
gland is tender. 

Remember that the microscope always shows the 
gonococci in the pus and the secretions should be 
examined for the cocci in all cases of vulvitis. 

Remember that cancer or vesicovaginal fistula by 
irritating discharges may cause a severe vulvitis 
and they should always be excluded by examina- 
tion. 

Remember that all varieties are contagious, and 
when occurring in institutions, strict isolation should 
be enforced. 

Treatment. — Remember two things are impera- 
tive: viz., rest in bed and cleanliness. The parts 
should be thoroughly cleansed with warm water to 
which is added a little tincture of green soap, or a 
saturated solution of boracic acid may be used. 



DISEASES OF THE VULVA. 33 

After a thorough cleansing twice daily (in the sim- 
ple form), a boric dusting powder should be used. 
In the severe form a hot sitz-bath twice daily will 
give relief and be cleansing. 

Eemember that the bowels should be kept freely 
open by the use of salines daily, but later the simple 
laxatives may be used. The diet should be light 
during the acute stage. 

Keep the urine bland and non-irritating by the 
free use of pure water. Should it be strongly acid, 
potassium acetate and the tincture of belladonna 
may be given; or, .should the urine be alkaline, ben- 
zoate of sodium or ammonium should be given. 

Local medication consists in douching the vulva 
with bichlorid of mercury solution (1: 2000 or 5000) 
with the labia separated by a piece of lint or cotton 
pledget soaked in the bichlorid solution. 

In the chronic form or in severe acute conditions 
lint compresses, soaked in Goulard's solution and 
warm water equal parts, may be applied to the 
vulva; or acetate of zinc gr. j to ounce of water, or 
sulphate of zinc, gr. ij to the ounce of water, may be 
used when an astringent action is needed. 

Wlien there are excoriations and erosions an oint- 
ment of benzoated oxid of zinc should be used. In 
the follicular form the vagina should be douched 
two or three times daily with normal salt solution, 
and a vaginal tampon used to collect the secretions 
and thus protect the vulva. The tampon .should be 
medicated with glycerite of boroglycerin. 



34 GOLDEN EULES OF GYNECOLOGY. 

Paint the affected parts with silver nitrate, gr. xx 
to the ounce, every three or four days, and apply 
compresses moistened with an alkaline solution — 
bicarbonate of soda gr. xxx to the ounce — continu- 
ously over the vulva and between the labia. 

In the severe cases the follicles should be punc- 
tured with a slender bistoury, and the contents 
squeezed out and painted with a solution of silver 
nitrate, half dram to the ounce, and apply the fol- 
lowing ointment: 

IJ lehthyoli 3 i j 

Phenolis gr. xxv 

Glycerini 3 iij 

Unguenti petrolati q. s. ad § ij 

Misce et fiat unguentum. 
Sig. : Apply locally. 

In the gonorrheal form, once or twice daily after 
thoroughly cleansing the parts, a douche of bi- 
chlorid, 1:2000 to 1:5000. 

The area should be thoroughly bathed with a 5 
per cent solution of silver nitrate or 10 per cent 
protargol at the beginning, then a daily application 
of a 2 per cent solution. 

Remember in gonorrheal vulvitis to give a good 
antiseptic vaginal douche and close the opening 
with cotton soaked in an antiseptic solution to pre- 
vent the extension of the infection along the genital 
tract. 

In diabetic vulvitis the vagina should be irrigated 
daily with a solution of corrosive sublimate, 1: 



DISEASES OE THE VULVA. 35 

2000, or a 1 per cent solution of lysol. An oint- 
ment of the following may be applied: 

I^ Acidi salicylic! gr. x 

Unguenti petrolati § j 

Misce et fiat ungiientum. 
Sig. : Apply locally. 

-Or: 

I^ Plienolis gr. xx 

Unguenti zinci oxidi §j 

Misce et fiat unguentum. 
Sig. : Apply locally. 

This will relieve the intense pruritis. 

Where excoriations or abrasions occur they 
should be painted every three or four days with a 
solution of silver nitrate gr. xxv to the ounce. 

In many of these cases, no relief will be obtained 
from the wet dressings; in these cases, after thor- 
ough cleansing, some dry, mildly antiseptic powder 
is of great advantage — viz., boracic acid and calo- 
mel, equal parts; calomel alone; borated talcum 
powder. 

BARTHOLINITIS. 

Eemember that these are racemose glands about 
the size of a bean, located in the labia majora at the 
junction of the middle and posterior third, and the 
ducts open in front of the hymen with an orifice 
about the size of a head of a pin. 

Eemember that the following may be the cause of 
an inflammation of these glands: gonorrhea; dis- 



36 GOLDEK RULES OF GYNECOLOGY. 

charges; extension of inflammation; suppuration of 
or a cyst of the gland. 

Eemember that by far the largest majority of the 
cases are due to the gonococci and that usually only 
one gland at a time is involved. 

Inflammation and suppuration of the glands of 
Bartholin are so common in gonorrheal infections 
that they are frequently referred to as sufficient evi- 
dence of the character of the infection, when they 
are found. 

Remember filth may be the cause and the staphy- 
lococci may be the pathogenic organisms found in 
the abscess. 

Remember that once the gonococci have infected 
the gland they may remain dormant, causing a 
.slight watery discharge that will infect the patient 
or others coming in contact with the secretions. 

Remember the subjective symptoms are: a sense 
of burning; a constant, sharp, lancinating or throb- 
bing pain with pruritis. All symptoms are made 
worse by standing or walking, but the recumbent 
posture gives relief. 

Remember that on examination there will be 
swelling and edema, and in severe cases, the swell- 
ing extends to the anus. The mouth of the duct of 
the gland is inflamed, and pus may be squeezed out. 

The evidence of pus is first apparent on the inner 
side of the labium. The tumor is round or oval; 
firm or fluctuating, and tender on pressure. 

Remember that a hernia into the labium is not 



DISEASES OP THE VULVA. 37 

tender on pressure, is elongated, and the most im- 
portant of all, there is succussion on coughing. It 
attains a large size if not treated and becomes ex- 
tremely painful; the patient walks with great diffi- 
culty, and is unable to find any position that is com- 
fortable; defecation and urination are painful; the 
abscess may burrow down around the anus and break 
into the rectum, causing a troublesome fistula. 

Remember that in strangulation of a hernia the 
sjmaptoms of intestinal obstruction will appear. 

Remember that many of these cases become 
chronic with cystic formation in the gland, due to 
obstruction of the duct, and are then to be differen- 
tiated from hydrocele in the canal of Nuck. The 
hydrocele is a larger tumor, is more translucent, and 
gives more sensation of fluctuation. 

Remember that in case of doubt a differential 
diagnosis can be fully determined by puncture with 
a needle. 

Treatment. — In very painful acute cases the ab- 
scess may have to be opened to afford relief to the 
patient, after which the cavity should be cleansed 
and packed with iodoform gauze. 

Remember that the vulvovaginal bulb lies just 
above the upper margin of the gland and should 
not be wounded. 

In acute cases with abscess formation it is far the 
best to remove the gland completely with a .sharp 
curette. Wash out the cavity with a bichlorid so- 
lution, 1:1000, mop the wound dry, and apply pure 



38 GOLDEN EULES OF GYNECOLOGY. 

carbolic acid to the entire cavity with a swab ; pack 
with gauze, and apply a T-bandage. 

If the abscess has spontaneously opened, then en- 
large the opening and proceed as above. 

Eemember that in chronic cases, as well as in the 
cystic form, the gland should be dissected out, care 
being taken not to rupture the cyst. 

Eemember that the nutrient artery enters the 
gland at the upper end; hence the dissection should 
be from below upward, and the vessel caught and 
ligated. Cleanse the cavity, apply carbolic acid, 
pack, and apply dressing. 

The removal of the gland is imperative in chronic 
cases and those with fistulous openings. 

CYSTS OF THE VULVOVAGINAL GLANDS. 

Remember that these cysts may be situated super- 
ficially or deeply. Those of the duct are always 
unilocular, while those of the gland may be mono- 
locular or multilocular, depending upon whether 
one or more lobules of the gland are involved. 

Remember that they may be the result of inflam- 
mation, usually gonorrheal; or due to an alteration 
of glandular secretion that cannot escape through 
the duct, thus causing a retention cyst. 

Remember that while small cysts cause no symp- 
toms the large ones interfere with walking and sex- 
ual intercourse. Friction to which the parts are 
subjected may cause irritation and inflammation, 
and eventually suppuration. 



DISEASES OF THE VULVA. 39 

Remember that cysts of the duct are globular or 
ovoid in shape and located under the mucous mem- 
brane at the base of the n^onphae, projecting into the 
vagina. 

Remember that a cyst of the gland is usually about 
the size of a hen's egg, located in the posterior part 
of the labium majus, and is freely movable under 
the overlying tissues. It is .smooth, ovoid, seldom 
transparent, dull on percussion, and found most fre- 
quently on the left side of the vulva. 

Remember that it is elastic on |)ressure, irredu- 
cible, and painless unless inflamed. 

Treatment. — The gland and duct should be dis- 
sected out, and the wound sutured, unless suppura- 
tion has occurred, when it should be packed. 

PRURITUS VULYiE. 

Remember that this is a symptom of some general 
or local lesion and the cause should be sought. 

Remember that it is a very troublesome symptom 
in diabetes, and all cases call for an. examination of 
the urine for sugar. 

Remember that malignant disease of the genital 
organs may cause a severe pruritus from an irrita- 
ting discharge and all cases occurring in elderly 
women call for a careful vaginal examination. 

Remember that it may be a reflex symptom de- 
pending upon seat-worms, and fissure, or it may be 
due directly to some anomaly of the pelvic organs, 
causing an irritating leucorrhea. Irritating dis- 



40 GOLDEN KULES OF GYNECOLOGY. 

charges are by far the most common cause of this 
trouble. 

Bemember that the itching is worse at night, or 
is made worse by warmth. 

Eemember that it may be due to a neurosis and 
may cause melancholy or insanity with suicidal 
tendencies. 

Eemember that pruritus may be caused by diges- 
tive disturbances or it may result from masturba- 
tion or sexual excesses. 

Treatment. — Eemember that in the treatment the 
cause must be sought and treated, as well as the 
local condition. 

The very first principle in the treatment is clean- 
liness, and the next is rest, to prevent, as far as 
possible, irritating the parts. 

Eemember that nitrogenous food should be re- 
duced and that milk diet is best. No alcoholic or 
other stimulants should be allowed, and the bowels 
must be kept open by a simple laxative. The free 
use of water usually keeps the urine bland, but if 
necessary, potassium acetate and belladonna may be 
given to correct an overacidity. 

Eemember that mild exercise may be advised, but 
do not forget that friction of the parts in walking 
makes the itching worse. 

Eemember that a good general tonic treatment is 
usually indicated and quinin, arsenic, iron, and the 
mineral acids are very beneficial. 

Eemember that mor|)hin should not be used but 



DISEASES OF THE VULVA. 41 

the bromids and cannabis indica allay nervousness 
and secure sleep. 

Sulplional gr. x to gr. xx; trional gr. xv to gr. 
XXV; paraldehyd ttlxx to xxx, given at bedtime and 
repeated in two hours, is often beneficial. 

Eemember that the most important thing in the 
local treatment is cleanliness. The vagina and 
vulva should be irrigated twice daily with normal 
salt solution or bichlorid solution, 1 : 3000, or a 2 
per cent solution of phenol in glycerin and water, or 
a solution of lead acetate may be used. All dis- 
charges of the vagina should be cleaned out, and a 
vaginal tampon placed against cervix to protect the 
vulva from the irritating discharges. 

Eemember that a compress of lead water and 
laudanum, or 2 per cent of phenol, often gives excel- 
lent results. 

Painting the surface with 10 per cent phenol; di- 
lute hydrocyanic acid 3 ii; acetate of lead gr. 1. to 
ounce of water, on a pledget of cotton held in a dis- 
secting forceps, is often beneficial. 

Eemember that the parts must be protected from 
the urine and carbolated vaselin is excellent. The 
following is an excellent ointment: 

I^ Mentholis gi*- x 

Ungueiiti creosoti 

Unguenti camphorse 

Ungiienti belladonnae 

Ungnenti petrolati aa 5 ij 

Misce et fiat unguentum. 
Sig. : Apply locally. 



42 GOLDEN KULES OF GYNECOLOGY. 

Or the following: 

I^ Phenolis gr. xxx 

Mentholis gr. xv 

Unguenti petrolati § j 

Misce et fiat imguentum. 

Sig. : Apply locally. 

Other good solutioii.s are strong solution of cor- 
rosive sublimate in emulsion of bitter almonds (gr. 3 
to ounce); chloroform (3 j) in glycerin (g j); di- 
lute hydrocyanic acid (firt ij to water § j). 

For the pruritus of diabetes, diabetic manage- 
mentj local cleanliness, and the use of borated tal- 
cum or a boracic acid ointment to protect the vulva 
are indicated. 

When pruritus is due to skin parasites mercurial 
and sulphur ointments .should be used. 

In cases due to seat-worms the infusion of quassia 
should be given in an enema. 

KRAUROSIS VULV^. 

Eemember that this is a progressive atrophy and 
contraction of the vulvar tissues, occurring in mid- 
or advanced-life, and resembles, somewhat, senile 
atrophy of the parts. 

Eemember that the cause is unknown but malig- 
nant disease of the vulva often develops from it. 

Eemember that the beginning of the condition is 
marked by the appearance of small, brown spots, 
irregular in shape, slightly depressed below the 
surface. 



DISEASES OP THE VULVA. 43 

Remember tliat these spots may be very painful 
to the touch and may cause a pruritus. 

Eemember that the labia and nymphse atrophy, 
forming a slight ridge upon either side. The vulva 
becomes shrunken, dry, and hard, and the normal 
appearance is lost. 

Treatment. — Eemember that the progress of the 
disease is very slow with no tendency to a spon- 
taneous cure. The treatment is palliative and 
surgical. 

Because of the resemblance to trachoma, John- 
stone recommends the yellow oxid of mercury oint- 
ment, in strength of from 1 to 3 per 'cent. First 
cleanse the vulva and vagina thoroughly with a 
spray of dioxid of hydrogen and apply the ointment. 
This is done twice a week. The patient is in- 
structed to apply the ointment twice daily to the 
external parts. The applications are made at longer 
intervals as improvement occurs, but the treatment 
is kept up for months. 

Strong solution of phenol is used to relieve the 
pruritus. 

Lint soaked in a saturated solution of lead acetate 
and laid over the parts often gives relief. 

Cracks and fissures should be touched with silver 
nitrate stick, and zinc oxid ointment applied. 

Remember that the removal of the diseased tissue 
is probably the best method of treatment. 

Remember that the incision is made along the 
juncture of the diseased tissue and the healthy skin 



44 GOLDEN RULES OF GYNECOLOGY. 

along the lateral and posterior margin of tlie vulvar 
orifice. Be sure to get well outside the diseased 
margin. 

Eemember the urethral orifice in dissecting the 
diseased tissues, and do not wound it but carry the 
incision around it. 

The diseased tissue is cut away; the mucosa of 
the vagina dissected loose, pulled out, and sutured 
to the healthy skin. 

ELEPHANTIASIS VULVAE. 

Eemember that, while this is a disease of the trop- 
ics, sporadic cases are seen over all the world. 

Eemember that the enlargement is due to the 
hypertrophy of the skin. 

Eemember that syphilis may cause a hypertrophy 
similar to elephantiasis but it is not so pronounced 
and mucous patches with other manifestations are 
present. 

Eemember that elephantiasis occurs in women be- 
tween the twenty-fifth and fiftieth years. 

It is probably due to the Filaria sanguinis hominis 
and is carried by the mosquito. 

Eemember that many cases, especially in the trop- 
ics, begin as an acute lymphangitis, with constitu- 
tional symptoms lasting about two weeks, then 
subsiding, leaving the vulva slightly enlarged. 
These attacks are repeated at varying intervals 
with increasing vulvar enlargement. 

Eemember that the labia majora are most fre- 



DISEASES OF THE VULVA. 45 

quently involved but that any or all of the vulva 
may be affected. 

Eemember that the parts are pendulous, the tis- 
sues hard, with smooth or warty surface and exco- 
riations, and fissures occur. 

Remember that in carcinoma of the vulva the 
growth is more rapid, induration deeper, and ulcer- 
ation more extensive. 

Treatment. — Remember that medicinal treatment 
is beneficial only in the early stages, and consists of 
rest in bed, saline cathartics, and hot or cold moist 
compresses, or a saturated solution of lead water 
and laudanum. 

Following the subsidence of the acute attack, an 
ointment of mercury or iodin is applied daily to the 
vulva, and pressure made upon the parts with a 
compress and a T-bandage. 

Calcium sulphid gr. j to gr. ij twice daily, given 
when the stomach is empty, is recommended. 

Remember that in the sporadic, or in the chronic 
cases, the complete excision of the diseased tissue 
gives the best result. 

Remember that the hemorrhage should be con- 
trolled by ligation of the vessels as the operation 
proceeds and the aseptic technic should be rigid, as 
the enlarged lymph-channels make suppuration par- 
ticularly dangerous. 

The edges of the wound are brought together, and 
as far as possible, the normal contour of the vulva 
is restored. 



46 GOLDEN" EULES OF GYNECOLOGY. 

VARICOSE VEINS. 

Eemember that pregnancy is the most frequent 
cause of this condition and it is more especially in 
cases of gestation associated with small pelvic 
tumors. 

Eemember that uterine displacement, chronic 
constipation, abdominal tumors, and prolonged 
standing interfere with the venous circulation of the 
vulva, hence are often causative. 

Eemember that symptoms are produced only when 
the tumor is large enough to interfere with the 
normal contour of the parts, when patient complains 
of aching, itching, burning, and a sensation of heavi- 
ness in the vulva. Coitus and walking cause suf- 
fering. 

Eemember that it occurs more frequently in the 
labia majora but other parts of the vulva may be 
affected. 

Eemember that the tumor is an elongated, irreg- 
ular, and knotted mass of a dark-blue color, while 
the veins under the skin are dilated and tortuous. 

Eemember that on palpation the mass is boggy 
and can be made to disappear by pressure. 

Eemember that the tumor may rupture into the 
tissues, during parturition, causing a hematoma, or 
externally causing a serious or perhaps fatal hemor- 
rhage. 

Varicose veins in the vulva frequently occur in 



DISEASES OP THE VULVA. 47 

pregnancy, owing to the weiglit and the pressure of 
the uterus. 

Although it is a very troublesome complication in 
pregnancy,, it usually disappears immediately after 
parturition, and needs no treatment afterward. 

Treatment. — Remember that the treatment may 
be either palliative or radical. 

Palliative treatment is used only during gestation 
and consists of mechanical support by pad or com- 
press over the tumor, held in position by a T-band- 
age. An abdominal binder should be worn to sup- 
port the uterus and relieve the pressure on the pelvic 
veins. Rest in the recumbent position for a few 
minutes several times daily. 

Should hemorrhage occur, firm pressure should 
be made over the bleeding point until aid arrives, 
when a deep catgut suture should be inserted to con- 
trol it. 

The radical treatment, where the varix is in the 
labia majora, is the same as the operation for the 
cure of varicocele in the male. The labium is made 
tense by traction, made by the assistant grasping 
the tissues above and below the most pronounced 
portion of the tumor. Make the incision over the 
varix. Expose the veins by dry dissection and pass 
a ligature around the vessels at the distal and prox- 
imal ends of the tumor. Tie and cut the veins at 
each ligature. 

The stumps are brought together and held in 



48 GOLDEN EULES OF GYNECOLOGY. 

elose apposition by securely tying the free ends of 
the distal and proximal ligatures. 

Close the "wound with sutures and cover the vulva 
with gauze held in position by a T-bandage. 

HYDROCELE OF THE LABIUM MAJUS. 

Eemember that this is a collection of serous fluid 
in the peritoneal sac that forms the canal of Nuck 
during fetal life. In the fetus the peritoneal cover- 
ing of the round ligament extends beyond the inter- 
nal ring, forming a pouch which is called the canal of 
Nuck. The persistence of this canal after birth 
forms the sac of the hydrocele. 

Eemember that it may be single or double and 
causes no inconvenience unless it becomes large, 
when mechanically it interferes with walking, sexual 
intercourse, and labor. 

Eemember that when seen early the tumor is lo- 
cated in the inguinal canal, but later it descends 
into the upper part of the labium. 

Eemember that the swelling is elastic, fluctuating, 
and translucent, no pain on pressure, and dulness on 
percussion. The tumor may be increased in size by 
bearing down or coughing. 

Eemember that it is important to differentiate 
hydrocele from hernia; and the following points 
should be borne in mind in making the distinction: 

1. The gradual development of the tumor with no 
local or general symptoms. 

2. Dulness on percussion. 



DISEASES OF THE VULVA. 49 

3. Translucency. 

4. Absence of inflammatory signs. 

5. Elasticity and fluctuation of the tumor, if en- 
cysted. 

Keep in mind that an inflamed hydrocele and 
strangulated hernia differ, in the absence of symp- 
toms of intestinal obstruction in the hydrocele. 
The insertion of a needle and the withdrawal of 
fluid will settle the doubt in diagnosis. 

Treatment. — Eemember that when the tumors are 
small they cause no trouble and may be left alone, 
or the patient given an ointment of oleate of mer- 
cury to rub into the skin. 

The tumor may be punctured and the fluid drawn 
off, but it will recollect. 

After the withdrawal of the fluid, an irritating 
solution like the tincture of iodin may be injected 
into the sac, causing an acute inflammation and ob- 
literation, but the danger is in forcing some of the 
solution through the abdominal opening into the 
peritoneal cavity. 

The best treatment is the dissection of the sac 
and the closure of the wound, suturing the individ- 
ual layers of the wall. The incision is made the 
entire length of the inguinal canal, and the sac ex- 
posed. It is then dissected out, twisted and ligated 
with a catgut ligature close to the internal abdom- 
inal ring, and the sac cut off about half an inch from 
the ligature. 

When suppuration occurs in a hydrocele it should 



50 GOLDEN- RULES OF GYNECOLOGY. 

be opened, curetted, and washed out with some anti- 
septic solution. The wound should be packed with 
iodoform gauze and allowed to heal by granulation. 

INGUINOLABIAL HERNIA. 

Eemember that this corresponds to the scrotal 
variety in the male. It descends through the in- 
guinal canal, following the round ligament. 

Eemember that the contents of the sac may be in- 
testine, omentum, uterus, or appendages, 

A hernia containing the uterus is comparatively 
rare; it is not nearly so common as scrotal hernia 
in the male, owing doubtless to the fact that there 
is an absence of the spermatic cord in the female, 
and consequently the tissues forming in the inguinal 
canal are stronger; the pregnant uterus has been 
found in such a hernia. 

Eemember that the patient complains of discom- 
fort or griping pain, usually following some exer- 
tion. There are gastrointestinal disturbances, such 
as dyspepsia and constipation. 

Eemember that the tumor appears first as a small, 
round swelling at the external ring, but after it has 
descended into the labium it is elongated and con- 
stricted at its upper end. 

Eemember that the contents of the hernial sac 
modify greatly the findings on physical examination. 

If it contains intestine, the tumor is smooth and 
elastic, and the size and tensity are increased on 
coughing, standing, lifting, or straining. It disap- 



DISEASES OF THE VULVA. 51 

pears on lying down, and when reduced by taxis a 
gurgling sonnd is heard when the gnt slips back 
into the abdominal cavity. The percussion note is 
tympanitic, and the characteristic impulse is felt 
when the patient coughs. 

When the sac contains omentum the tumor is ir- 
regular, feels doughy, and the percussion note is 
dull. 

No gurgling sound is heard when the contents are 
replaced into the peritoneal cavity, and the impulse 
on coughing is slight. If the sac contains both in- 
testine and omentum, the signs vary over different 
areas of the tumor. 

Eemember that, when the uterus forms the con- 
tent of the sac, the tumor is hard, dull on percussion, 
with no impulse on coughing. 

Eemember that bimanual examination reveals the 
absence of the uterus and vaginal examination re- 
veals the cervix pulled toward the affected side. 

Keep in mind that when a pregnant uterus forms 
the contents of the sac the tumor gradually in- 
creases in .size as gestation progresses. 

Eemember that hernia must be distinguished from 
hydrocele, enlargement of the vulvovaginal glands, 
and tumor of the labium majus. 

Treatment. — Eemember that treatment may be 
palliative or radical. When the contents of the 
hernial sac can be returned to the abdominal cavity 
and retained by a well-fitting truss, the palliative 
treatment may be followed with a certain degree of 



52 GOLDEN RULES OF GYNECOLOGY. 

safety. But it .sliould be made very plain to the pa- 
tient that it is only for the purpose of temporary 
relief or until a more convenient time," when she can 
submit to a radical cure; that it is extremely danger- 
ous for a woman (at least in the child-bearing period 
of life) to have a hernia. 

Eemember that with incarceration or inability to 
prevent the escape of abdominal viscera with a truss 
the operative procedure becomes imperative. 

Eemember that the surgical procedure offers the 
only cure and during the child-bearing period this 
is of great advantage for the future safety of the 
patient. 

Eemember that the steps of the operation are the 
same as for the cure of inguinal hernia in the male, 
with the exception of the absence of the spermatic 
cord, which of course does not necessitate a recon- 
struction of the inguinal canal. If the hernial sac 
contains the uterine fundus and pregnancy occurs, 
abortion is more than likely at the third or fourth 
month. 

Eemember that in operation for the cure of a 
hernia of the uterus, where it is acutely inflamed, it 
may necessitate the removal of the uterus also. 

CHANCROIDS. 

Eemember that the primary chancroid may occur 
on any part of the vulva but is most commonly 
found on the fourchette, labia majora, nymphse, and 
vestibule. 



DISEASES OF THE VULVA. 53 

Eemember that secondary inocnlations from tlie 
original ulcer are very common in women, due to 
the proximity of the two sides of the vulva and the 
difficulty of keeping the parts clean. 

Remember that chancroids are usually found in 
the lower class of prostitutes because of their indif- 
ference with whom they cohabit, and uncleanliness. 

Remember that' the course and duration are less 
favorable in females than males, because the exter- 
nal genitalia are constantly exposed to the leucor- 
rheal discharges, menstrual blood, urine, and fric- 
tion in walking. 

Remember that chancroids usually appear in five 
or six days after sexual intercourse and never later 
than twelve days. 

Remember that they are rapid in development and 
there is a great tendency to suppuration of the in- 
guinal lymphatic glands. 

Remember that the inflammatory reaction of the 
ulcer makes it very painful to the touch and that 
it has a punched-out appearance, but there is no in- 
duration around the ulcer and the edges are under- 
mined. 

Remember that the floor of the ulcer is uneven 
and covered with a yellow debris. The secretion is 
yellow or brownish and has a penetrating nauseous 
odor. 

Remember that the discharge is infectious and 
autoinf ectious, so that new ulcers may continue to 
form. 



54 GOLDEN KULES OF GYNECOLOGY. 

Now keep in mind that there is often great pain 
and suffering accompanying chancroids — tliis pain 
and suffering is usually in proportion to the amount 
of ulceration — walking becomes difficult and mic- 
turition painful; these patients will have a sick and 
agonizing expression of the face. 

Eemember that if not checked the area of ulcera- 
tion may become quite extensive, the labia may be 
penetrated from ulceration completely through the 
tissue, and when finally it is made to heal the vulva 
will present a scarred and ugly appearance. 

Eemember that these patients are exceedingly 
anxious to be assured that they are not the victims 
of syphilis; this is often quite difficult to do in view 
of the facts that promiscuous intercourse may have 
been indulged in, making a history impossible or 
worthless, and we may have a mixed infection. If 
in doubt, it is best to wait and anticipate secondary 
manifestations before instituting general specific 
treatment. 

Treatment. — Remember that the first thing to do 
is to convert the sore into a non-specific ulcer and 
this may be done by cauterizing the ulcer. The 
thermocautery may be used, but the ulcer should first 
be anesthetized by a solution of cocain. 

The application of undiluted phenol to the ulcer, 
followed by alcohol, or the use of nitric acid, may 
be used to destroy the infection. 

The vagina and vulva should be thoroughly 
douched with a hot lysol solution and dried, and the 



DISEASES OF THE VULVA. 55 

ulcer dusted with iodoform, aristol, or the subiodid 
of bismuth. 

The labia should be held apart by a pledget of 
cotton, and a T-bandage applied. 

The parts should be cleansed daily with hot lysol 
solution, or bichlorid of mercury 1 :2000, followed 
by saline solution and powder dusted on the ulcer. 

Now remember that these unfortunate women 
apply for treatment largely on account of the pain 
they suffer. Some attempt has been made to treat 
themselves until the pain becomes unbearable. 

Compresses of lead and opium, frequently 
changed, are often useful, and compresses wrung 
from hot water give relief. Sometimes pledgets of 
cotton saturated with 2 per cent cocain solution 
have to be applied to the ulcers in order that the 
patient may have a few hours' rest. 

In some the pain and progress of the chancroids 
are so persistent that they seem to resist nearly all 
kinds of treatment. The author found, by referring 
some of these cases to Dr. H. M. Lyle (dermatolo- 
gist), that almost instant relief from pain was ob- 
tained from the use of the so-called leucodescent 
light. After a few treatments the pain will not re- 
turn, the secretions from the ulcers cease, and they 
present a healthy granulating surface. We now 
have in our clinic a 62-candle-power electric light 
with a strong reflector, with which we treat these 
cases, applying heat for five to ten minutes daily, 
from which we obtain happy results. In conjunc- 



56 GOLDEN" RULES OF GYNECOLOGY. 

tion we have used scarlet-red ointment 5 per cent 
(P. D. Co.), which we believe is of much value. ' 

When healthy granulations begin to form, discon- 
tinue the powder and apply a stimulating ointment, 
such as 2 per cent of phenol in benzoated oxid of 
zinc ointment, or one part of the ointment of mer- 
curic nitrate to seven of va.selin. If a bubo de- 
velops, it should be painted with' the tincture of 
iodin, and the patient kept in bed; and should it 
persist and suppurate, it should be freely incised, 
and the gland curetted away. Wash out the cavity 
with hot lysol solution, dry, and pack with gauze. 

The general health of the patient may be such as 
to demand an iron tonic, rest, and plenty of good 
food. 

Remember that there is always danger of a gen- 
eral sepsis in all these cases, and the gravity of such 
in nowise differs from other septic infections. 

Remember that exuberant and unhealthy granu- 
lation of an ulcer demands the application of silver 
solution, or the stick may be used. 

CHANCRE. 

Remember that the primary lesion or hard 
chancre is frequently not to be found on the female 
genitalia, thus being the opposite to the rule in the 
male. It is sometimes found on the lips or in the 
mouth. The most common situation of the chancre, 
however, is on the labia majora. 

Remember that chancre is ^^ery frequently over- 



DISEASES OF THE VULVA. 57 

looked -unless the examination is most carefully 
made, owing to the conformation and the relation 
existing between the various parts. 

Eemember that the appearance of the secondary 
or tertiary symptoms may be the first intimation of 
syphilis and no history of the primary sore be ob- 
tained. 

Eemember that the primary lesion is, as a rule, 
single, but may be multiple or mixed with soft 
chancres. 

Eemember that the ulcer is superficial, flat, of a 
reddish or grayish color with a smooth floor. There 
is an area of induration around the ulcer, which is 
hard like cartilage, and the edges are never under- 
mined. 

Eemember that the enlargement of the inguinal 
glands usually occurs but they do not suppurate. 

Eemember that a syphilitic ulcer does not present 
the angry appearance and destructive characteris- 
tics of the chancroid. The edges slope inward, and 
there is not such a marked inflammatory reaction in 
the adjacent tissues. 

Eemember that the period of incubation is from 
two to three weeks, or even longer, thus differing 
markedly from chancroid. 

Eemember that the secondary lesions on the vulva 
usually appear as mucous" patches, or condylomata. 

The condylomata vary in size from a split pea to 
a thumb-nail and are slightly elevated and flattened, 
with a shedding of the epithelium covering the area. 



58 GOLDEN KULES OP GYNECOLOGY. 

They may appear at any time during tlie first twelve 
months and may be single or multiple. Tliey are 
most commonly found on the labia minora and the 
inner surface of the labia majora. 

Eemember that the Spirochceta pallida can be 
found in all forms of syphilis and it is important to 
examine secretions or pieces of tissues. 

Treatment. — Eemember that it is very important 
to make a diagnosis before adopting any line of 
treatment that will influence the clinical picture. 

After a diagnosis is made the local treatment is 
simply that of cleanliness. 

Bichlorid 1:2000, as a wash, lysol 2 per cent so- 
lution, are excellent. After cleansing use some dust- 
ing powder. Calomel is frequently used as a dust- 
ing powder, as it relieves irritation. Where there 
is a tendency to bleed, a 10 per cent solution of 
copper sulphate is goodj or the use of the silver 
stick. 

If the case is seen early, it is good practice to 
excise the sore with a .sharp electric cautery. 

The chancre usually heals without any trouble, 
and one of the greatest difficulties is to make the 
patient understand that she is not entirely well and 
will not be until she has undergone a thorough 
course of general medication. 

Now remember that it is largely for this reason 
that no internal treatment should be given, if there 
is the slightest doubt in the diagnosis, until after 
the secondary manifestations appear. At any rate, 



DISEASES OF THE VULVA. 59 

the visual demonstration is the most impressive 
to the patient, and then, of course, internal treatment 
should be instituted. 

VERRUCA. 

Eem ember that there are two varieties: verruca 
vulgaris, or common wart; and verruca acuminata, 
or venereal wart. The vulgaris usually is not ten- 
der and often appears in groups. It may or may 
not be pedunculated and is attached usually by a 
broad base. 

Eemember that verrucae acuminata are cauliflower 
excrescences. They grow very rapidly and may at- 
tain the size of a fist. 

Eemember that the color will depend on their vas- 
cularity and the condition of the epidermis. If the 
epidermis is present the surface is dry, and the color 
that of the surrounding skin or mucosa. When the 
epidermis is removed by secretion or maceration, 
they are deep-red or purplish, and the discharge 
purulent, offensive, and highly irritating. 

Eemember that they may be found any place on 
the vulva, around the anus, and on the inner surfaces 
of the thighs. 

Wlien they are large they interfere with walking 
and coitus. 

Eemember that in old women they may undergo 
malignant degeneration or become gangrenous and 
cause death. 

Eemember that the discharge is virulent and may 



60 GOLDEN EULES OF GYNECOLOGYo 

cause purulent oplitlialmia, following labor, or may 
.cause urethritis in male, or produce general sepsis 
in the patient. 

Treatment. — Geneeal.-^-Iu some cases there is an 
impairment of the general system ; especially in 
strumous or anemic children, it will be necessary to 
administer a general tonic and hematonic. The fol- 
lowing are recommended: arsenic, mineral acids, 
iron, bitter tonics, and cod-liver oil. 

Tincture of thuja irtv (t. i. d.); tincture of iodin 
iTLx, twice daily are considered to have a more or 
less specific action upon warts. 

Local. — The common wart is best treated by ex- 
cising with a pair of scissors and cauterizing the 
base with phenol, or the actual cautery. 

Venereal warts require the vaginal discharges re- 
moved by daily antiseptic douches. 

Next is excision, if possible, of the growth. This 
may be done under local anesthesia if growths are 
not too extensive, when a general anesthetic should 
be given. 

The wound should be cauterized and dressed with 
antiseptic powder, such as calomel or equal parts of 
bismuth subnitrate and prepared chalk, or equal 
parts of calomel and salicylic acid. 

ADHESIONS OF THE CLITORIS. 

Eemember that the folds of the nymphse may be- 
come adherent as a result of irritating discharges, 
inflammation, and uncleanliness. 



DISEASES OF THE VULVA. 61 

Eemember that the symptoms are local and reflex 
and they depend upon the extent of the adhesions. 

Remember that in some cases sebaceous matter ac- 
cumulates under the hood of the clitoris, producing 
irritation that causes local tenderness and pain. 

Remember that the adhesions may cause mastur- 
bation or be the exciting cause of a morbid sexual 
desire. 

Remember that adhesions are regarded by many 
authorities as a common cause of ill health in young 
women and an important factor in many of the vari- 
ous neuroses. 

This is a very common trouble in little girls, but 
from either false modesty or a failure to recognize 
its importance, it is rarely treated. 

Many of the thin, sickly looking little girls would 
develop into robust children (just as boys so fre- 
quently do after circumcision) if the hood of the 
clitoris .should be thoroughly freed, and other points 
of irritation aroimd the vulva be relieved. 

Remember that a physical examination reveals 
the adhesions and it is decidedly not an unwise plan 
to examine all girl babies in second year for these 
adhesions. 

Remember also that the lack of sexual desire in 
married women may be caused by the hood com- 
pletely covering the clitoris, to which it is bound 
down by adhesions. 

This portion of the female genital apparatus has 
not received proper attention- A woman marries, 



62 GOLDEN EULES OF GYNECOLOGY. 

and if she has to be a sexual slave, without sharing 
in its bles.sings, it is only considered that it is as it 
should be; notwithstanding the fact that she is well 
developed, capable of bearing children, and that 
there is no reason why she should not be able to 
properly perform the sexual act. 

Treatment. — Remember that, the only treatment is 
the separation of the adhesions by blunt dissection. 

It is very difficult to break up these adhesions in 
a satisfactory way, in young girls at least, without 
a general anesthetic. If the patient is a married 
woman and can tolerate a little pain, it may be done 
by cocainizing the parts well with 10 per cent cocain 
solution, but it is not a very pleasant procedure for 
any woman; hence a general anesthetic is preferable. 

Thoroughly expose the glands, cleanse the parts, 
and smear the raw surfaces with 2 per cent car- 
bolized zinc oxid or vaselin. 

The prepuce should be pushed back daily, and the 
ointment applied until there is no longer any danger 
of the formation of adhesions. 

ADHESIONS OF THE LABIA. 

Remember that this occurs more frequently in in- 
fancy, childhood, senility, and the unmarried. 

It usually occurs between the nymphse, but the 
labia majora, in rare instances, may be united. 

Remember that inflammation, irritating dis- 
charges, and uncleanliness are the most common 
causes. 



DISEASES OF THE VULVA. 63 

Remember that there may be all variations from 
the cementing of the nymphse by abnormal dis- 
charges to a firm organic nnion due to the destruc- 
tion of tissue, and sometimes it is congenital. 

Eemember that the patient complains of irritation 
and on urination the stream may be deflected up- 
ward. The menstrual flow may be retained in the 
vagina or be discharged with difficulty. Coitus is 
impossible or may be partly accomplished through 
the urethra; and if adhesions take place when a 
woman is in the pregnant state, the adhesions will 
form an obstruction to the delivery of the child. 

Treatment, — Where the labia are simply glued to- 
gether they should be forcibly separated with the 
thumbs, a vaginal douche given, and the labia kept 
apart with a pledget of cotton covered with phenol- 
ated vaselin, and a compress with a T-bandage ap- 
plied. The dressing should be changed daily for a 
week or ten days. 

Where adhesions have become organized or when 
the condition is congenital, it will be necessary to do 
a cutting operation. 

If there is a partial opening, a grooved director 
is passed into the vagina, being careful to go below 
the urethra, and the labia are divided with a scalpel 
along the line of false union. 

When no opening is present, and it can be deter- 
mined that the closure has been caused by adhesions, 
the urethra is kept out of the way by a sound. The 
parts are put upon the stretch by lateral pressure 



64 GOLDEN KULES OF GYNECOLOGY. 

with the thumb and index finger, and an incision 
is made with a scalpel along the line of adhesions. 
As soon as the opening will admit it, the index fin- 
ger should be introduced, and the incision extended 
the full length of the labia. The cut edges on each 
labium should now be coapted by chromic catgut 
sutures. The dressing to be applied islhe same as 
described under forcible separation. 

Eemember, however, that most frequently, when 
the labia are united and the vaginal orifice is closed, 
the condition is usually congenital, with infantile 
uterus and appendages, or an absence of one or all 
of them. 

Eemember that frequently this condition is not 
appreciated by the mother, and in rare cases by the 
girl, until she has some thought of marriage. The 
author saw an Italian girl of 19, who applied for 
treatment three weeks after marriage. She had no 
vagina, and efforts at sexual intercourse had dilated 
the urethra so that it would admit the index finger 
to the depth of about an inch. 

If she has not had the menstrual molimen and 
evidence of vaginal and uterine distention from the 
menstrual secretions, a very thorough examination 
should be made to ascertain if she has a uterus and 
ovaries; and if so, if they are fully developed or 
infantile in type. 

Eemember that if they are absent or rudimentary 
marriage should be discouraged as well as any effort 
to establish a vaginal canal. The disappointment 



DISEASES OF THE VULVA. 65 

may be great, but not nearly so great as an impossi- 
ble married life or an nnsatisfactory attempt to es- 
tablish a canal, with encouragement that sooner or 
later must be blasted. 

HERPES. 

Eemember that this acute inflammatory affection 
is not contagious. It is frequently found in connec- 
tion with menstruation in fleshy or neurotic women. 

Keep in mind that anything causing irritation and 
congestion of the vulva often causes herpes, thus, in 
prostitutes, pelvic diseases, and pregnancy. 

Eemember that the eruption is preceded by ten- 
derness, pain, burning, or itching, and in some cases, 
headaches, fever, and chilliness. 

Remember that the lesion of herpes begins as a 
red spot, varying in size from a pinhead to a split 
pea. These soon change to vesicles filled with a 
clear serous or seropurulent fluid, with a red base, 
and usually arranged in groups. 

Remember that the presence of heat, moisture, and 
friction soon converts the vesicle into an ulcer. 
These coalesce, and the discharge becomes offensive. 

Remember that in eczema the vesicles are smaller, 
less flattened, there is more swelling of the skin, and 
a tendency of the disease to extend; while in herpes 
the vesicles occur in successive crops and are ar- 
ranged in groups. They are situated oh an inflamed 
base, and the attack is short in duration. 

Keep in mind that chancroids give a history of 



66 GOLDEN EULES OP GYNECOLOGY. 

sexual intercourse five or six days, and never over 
twelve days, before the eruption appears. 

Eemember that the chancroid ulcer has a punched- 
out appearance, the margins are undermined, and 
there is the characteristic involvement of the in- 
guinal lymph-glands. 

Eemember that chancre develops slowly, is single; 
the base is indurated, and the margins of the ulcer 
are sloping. There is an enlargement of the in- 
guinal glands, but they seldom suppurate. 

Eebaember that the course of herpes is short, 
usually lasting one or two weeks. The ulcers are 
generally superficial and rarely cause scars. 

Treatment. — Eemember that some of these cases 
need general as well as local treatment. 

The cause should be sought and removed if possi- 
ble. The digestive and urinary systems must be 
kept in normal condition. 

During the acute stage walking or exercise of any 
kind should be forbidden. 

A good general tonic should be given. The most 
commonly used drugs are the mineral acids, arsenic, 
iron, and quinin. 

Local treatment should be carefully carried out. 

The vulva and vagina should be douched once or 
twice daily with a hot lysol or bichlorid solution. 

A hot sitz-bath is very soothing and beneficial. 

A dry vaginal tampon should be inserted to pro- 
tect the vulva from uterine or vaginal discharges. 
. After the douche the vulva should be thoroughly 



DISEASES OF THE VULVA. 67 

dried, and a dusting powder used. Talcum, lycopo- 
dium, or oxid of zinc may be used. 

For severe cases solution of silver nitrate, gr. x to 
g j, may be painted on the vulval area involved, or 
phenol, 2 per cent solution in glycerin, is excellent. 
A T-bandage holds a compress in positiono 

ECZEMA. 

Eemember that this is a skin affection that pre- 
sents various forms of lesions or a combination of 
them accompanied with itching, infiltration, and 
often attended with a discharge and the formation 
of scales and crusts. 

Eemember that the vulva is particularly liable, on 
account of the frequency of local and pelvic condi- 
tions that cause chronic irritation and congestion. 

Remember that a diabetic urine will cause an in- 
tense eczema, as will also the irritation produced by 
a vesicovaginal fistula. 

Remember that pruritus vulvae is the most promi- 
nent symptom, while pain and burning are often com- 
plained of. 

Eczema may be confined to the labia majora, or it 
may extend to the mons veneris, the perineal and 
anal regions, or the lower portion of the abdomen. 

Remember that the senile changes that occur at 
the menopause appear to predispose to eczema of the 
vulvaB, and gastrointestinal disorders and gout are 
strong predisposing factors. 

Treatment. — Remember that the diet is important. 



68 GOLDEN EULES OF GYNECOLOGY. 

Alcoholics, spices, and highly seasoned foods must 
be forbidden. The digestive and eliminating organs 
must be kept at par. 

Eemember that certain articles of food — such as 
pork, cheese, and shellfish — have an injurious effect 
and should be excluded. 

Locally, cleanliness is of first importance in the 
treatment. The scabs and scales must be thoroughly 
removed so that the medicament may come in con- 
tact with the diseased surface. Instruct the patient 
to stoop over a pan of warm water, and using some 
good soap, such as sapo viridis, to wash the parts 
thoroughly with the hand and not to use a sponge 
or cloth. Dry the parts thoroughly. If this fails 
to remove the scales or crusts, a bland oil — such as 
olive, cotton-seed, or linseed — should be applied 
freely, and after the scales or crusts have softened, 
then wash the parts. 

Should the soap and water aggravate the lesion, 
then the alkaline bath must be substituted. This 
consists of one ounce of bicarbonate of soda in five 
gallons of water. In acute cases this bath is very 
effective and should be used three or four times a 
day of fifteen minutes each. 

In the use of lotions distilled water should be used, 
as hard water irritates the parts. Sedative and as- 
tringent lotions are often useful and are applied by 
means of lint compresses which are held in position 
with a T-bandage. Lead water and laudanum allay 
itching and burning. Equal parts of glycerin, lime- 



DISEASES OF THE VULVA. 69 

water, and distilled water are excellent, especially 
when the affected parts are hot and dry. Serous 
oozing, burning, and pruritus are relieved by bicar- 
bonate of soda or potassium, 5 ij to one quart of dis~ 
tilled water. 

Weak solution of carbolic acid, thymol, or alum; 
black wash; saturated solution of boric acid; and 
dilute solution of peroxid of hydrogen are all useful. 

Many cases are best treated by ointments. Lano- 
lin is the best base. A very excellent combination 
is the following: 

IJ Ichthvoli 3 ij 

Unguenti hydrargyri ammoniati 

Ungiienti zinci oxidi afi q. s. ad 5 i j 

Misce et fiat iniouentum. 

Sig. : Apply locally. 

Dusting powders may be used. They protect the 
parts and exert a sedative or astringent action. 
Starch, boric acid, talcum, subnitrate of bismuth, 
and calomel furnish us a list from which a dusting 
powder may be selected. 

Bland oils, as cotton-seed, olive, almond, may be 
used over the affected parts. 

THRUSH. 

Eemember that the same organism, Saccliaro- 
myces albicans, causing parasitic stomatitis, causes 
thrush of the vulva and vagina. 

Eemember. that the disease is most frequently seen 
in nursing women, and those exhausted bv some 



70 GOLDEN RULES OF GYNECOLOGY. 

chronic condition, as tuberculosis, diabetes, or ma- 
lignant disease. 

Eemember that the surface is covered with slightly 
elevated, whitish spots that have a tendency to 
coalesce and eventually leave a small, painless ulcer. 

Treatment. — Eemember that the vulva and vagina 
should be douched twice daily with an antiseptic 
solution, as lysol, or bichlorid (1:2000). 

A tampon, saturated with 25 per cent ichthyol in 
glycerin, should be introduced into the vagina. 
Dust the vulva with a powder composed of aristol, 
calomel, and subnitrate of bismuth, equal parts. 
Separate the labia, and apply T-bandage. 

When the ulcers are slow about healing, touch 
them with silver stick, or silver solution, 2 per cent. 

The patches should be washed several times daily 
with peroxid of hydrogen. 

The constitutional conditions should receive ap- 
propriate medication. 

SIMPLE DERMATITIS. 

Eemember that this is frequently known to the 
patient as chafing and is found most often in fleshy 
women. 

Eemember that this is produced by the rubbing 
together of folds of the skin. This is especially 
likely to occur where there is a leucorrheal dis- 
charge. 

Eemember that the local conditions vary between a 
simple erythema and a severe inflammation, depend- 



DISEASES OF THE VULVA. 71 

ing Tipon the severity of the cause and the ^ ' tender- 
ness'^ of the skin. 

Eemember that the condition gives rise to more 
or less of burning and itching, and in severe cases 
there is a serous secretion, which chafes both the 
vulva and the inner surfaces of the thighs. 

Treatment. — Keep in mind that cleanliness is very 
important and the parts should be thoroughly 
cleansed by a carbolic wash, or the use of baking 
soda, a tablespoonful to a pint of water. The parts 
should be dried, and a drying antiseptic dusting 
powder used. The following make good dusting 
powders: boric acid, aristol, rice powder, or 

R Zinci oxidi 

Magnesii carbonatis 

Phenylis salicylatis 

Amyli aa 5 sa 

Misce et fiat pulvis. 

Sig. : Dust freely over parts. 



This washing should be done from three to six 
times daily. 

In severe cases keep patient in bed and apply 
gauze soaked in calamine lotion: 

B Zinci oxidi 3 iv 

Calamiiiaj praeparattie 3 iss 

Glycerini ^ j 

Liquoris ealeis q. s. ad S viij 

Misce et fiat lotio. 

Sig.: Apply externally. 

In cases that are required to be about their work, 
an ointment may be used : 



72 GOLDEN EULES OF GYNECOLOGY. 

IJ Zinci oxidi 3 ij 

Phenylis salicylatis gr. ^v 

Adipis lanse hydros! 5 j 

Unguenti aquae rosae q. s. ad 5 ij 

Misoe et fiat unguentum. 

Sig. : Apply to parts frequently. 



Or: 



IJ Zinci oxidi 3 ss 

Bismutlii subcarbonatis 3 ss 

Phenylis salicylatis gr. x 

Petrolati 5 j 

Misce et fiat unguentum. 
Sig. : Apply freely to parts. 

Or: 

IJ Bismuthi subnitratis 3 iss 

Phenylis salicylatis gi'- xij 

Adipis lanae hydros! 3 ij 

Unguent! zinci oxidi 3 vj 

Misce et fiat unguentum. 

Sig. : Apply freely to parts. 

ERYSIPELAS. 

Eemember that this is an acute, contagious in- 
flammation of tlie skin, caused by the Streptococcus 
erysipelatis. There must be a port of entry through 
a lesion, however small, and eczema, herpes, and 
erosions all furnish excellent conditions. 

Eemember that the general symptoms are chill, 
rapid rise of temperature, nausea or vomiting. The 
pulse is rapid, soft, but has a good volume. 

Remember that locally the parts become swollen, 
of a red, shining appearance, and the margins may 
be felt because of elevation above healthy skin. The 



DISEASES OF THE VULVA. 73 

line of demarcation is sharp, but tlie edges of the 
inflammation progress daily; while resolution occurs 
in center or oldest part of the affection. The pa- 
tient complains of pain, heat or burning, and 
pruritus. Vesicles may form over the involved 
area. 

Remember that in severe cases abscess formation 
may occur, or where the edema is great gangrene 
may follow. 

Treatment. — Eemember that the treatment is both 
local and general. 

Gen^ekal. — The bowels should be moved with ca- 
thartic or enema of water and glycerin. 

Where the patient is robust, calomel, followed by 
saline, should be the cathartic of choice. 

In weak, asthenic cases violent purging does harm 
by further depressing the vital powers, and the 
enema of glycerin and water should be used. 

The patient should be confined in bed, and the use 
of a bedpan is important, so that the inflamed area 
will not be mechanically injured by friction. 

Eemember that it is important that the patient's 
strength and vitality should be conserved by every 
means, and stimulants used freely when needed. Of 
the stimulants none are better than strychnin or 
whiskey given to full effect. 

The fever should be controlled by the ice cap and 
sponging. Either water, or water and alcohol or 
vinegar, may be used. 

Eemember that under no conditions should anti- 



74 GOLDEN RULES OF GYNECOLOGY. 

pyretic drugs be used, because of. their depressing 
effect on the heart. 

Pilocarpin hydrochlorate hypodermatically, gr. % 
to %, may be used to great advantage in strong 
healthy subjects. When used it should be early in 
the disease. 

Quinin hydrochlorid in two-grain doses every 
three hours is beneficial, because of its power in 
small doses of stimulating the leucocytes, but the 
massive doses should never be used. 

Tincture of the chlorid of iron has been thought 
to be very beneficial. 

Local. — A good warm antiseptic douche for the 
vulva and vagina is indicated. 

Lysol, 1 to 2 per cent, corrosive sublimate solu- 
tion (1:4000), or phenol solution are all good. 

The parts should be dried, when either of the fol- 
lowing may be applied: 

Crede's ointment rubbed thoroughly into the in- 
flamed area; or equal parts of ichthyol, tincture of 
iodin, and glycerin painted over the area infected; 
or an ointment composed of equal parts of ichthyol 
and lanolin may be rubbed well into the parts; or a 
hot strong lysol compress may be applied; in all 
cases a dry dressing as a covering and a T-bandage 
are applied. 

The dressing should be changed twice daily until 
the inflammation begins to subside and desquama- 
tion begins, when the benzoated'zinc oxid ointment 
should be used. 



DISEASES OF THE VULVA. 75 

Where the pain and local irritation are severe a 
lotion of lead water and laudanura may be advan- 
tageously used. 

The hypodermic injection of bichlorid of mercury 
into the healthy skin immediately surrounding the 
infected area may be used. The solution is in the 
proportion of 1 to 4000 of water. It is very painful. 

VAGINISMUS. 

This affection is due to a hyperesthetic condition 
of the vulvovaginal orifice, causing painful and spas- 
modic contraction of the muscles of the floor of the 
pelvis. 

Eemember that the condition is usually found in 
young, neurotic, hysterical women. It is frequently 
caused by a carbuncle, erosion, fissure, or irritable 
hymen. Lead poisoning and masturbation are said 
to be frequent causes. 

Eemember that the intensity of the symptoms 
varies. There are cases where the attempted intro- 
duction of a urethral catheter or digital examination 
will cause a painful spasm. 

Where the cause is a local lesion the convulsion 
will develop slowly, and the patient locates the pain 
at the site of the lesion; but the sensitive area grad- 
ually extends until the entire surface of the vulva 
becomes hyiDeresthetic. 

Eemember that many of the cases suffer from neu- 
ralgic dysmenorrhea, and the bladder and rectum 
eventually become irritable. 



76 GOLDEN RULES OF GYNECOLOGY. 

Treatment. — Remember that tlie treatment should 
be directed to removal of the cause as well as for the 
temporary relief of the symptoms. 

Remember that cases depending upon brutal or 
ineffectual coitus present no local lesion and treat- 
ment demands proper education in the sexual act. 

Remember that a 5 per cent solution of cocain ap- 
plied on a pledget of cotton for a few minutes will 
relieve slight cases brought on by sexual intercourse. 
The application should be made just before coitus. 

Painting the affected parts twice a week with a 4 
per cent solution of silver nitrate, or the use of rectal 
suppositories of opium and belladonna, is often bene- 
ficial. 

Remember that severe cases demand a more or 
less radical procedure. Two methods may be em- 
ployed to advantage: viz., forcible dilatation; or in 
extreme cases incising through vaginal mucous 
membranes and into fascia in each lateral sulcus, 
producing an artificial perineal laceration, as it 
were. 

Forcible Dilatation. — A general anesthetic is re- 
quired, and the patient is placed in the dorsal po- 
sition, with the knees flexed on the abdomen. 

Now, by using the thumb, the vaginal entrance is 
thoroughly stretched. If the cases require it, a 
Sim.s' glass vaginal plug may be introduced to pre- 
vent contraction (this is rarely necessary if the 
stretching has been thorough). The patient should 
be kept in bed for a week or ten days. If it is found 



DISEASES OF THE VULVA. . 77 

necessary to use the glass plug, remember that it 
will in all probability have to be removed during 
defecation and micturition, or it has to be removed 
daily for the use of antiseptic vaginal douches. 
Now this handling of the glass plug causes much 
pain and annoyance, and the chances are that its 
use will have to be discontinued after one or two 
attempts to reinsert it. 

Eemember that to be of benefit the plug should be 
sufficiently large to stretch the parts; if it can be 
tolerated by the patient, she should be instructed, 
after about two weeks under physician's care, to in- 
troduce the plug at bedtime and remove it in the 
morning. This treatment should be continued for 
five or six months if necessary, and the patient 
should report frequently to her physician for ex- 
amination and advice. 

Eemember that these patients should be required 
to take a certain amount of systematic exercise in 
the open air; plenty of rest and sleep is necessary, 
and a good general tonic is indicated. 

Opeeation^. — Patient in dorsal position; two deep 
incisions about one inch long are made in each vag- 
inal sulcus. They unite at the perineal center and 
are continued halfway down to the anus. The in- 
cisions should be deep enough to divide the fascia 
and underlying muscles. The incisions are closed 
with a catgut suture. 



CHAPTER III. 
DISEASES OF THE VAGINA. 

ACQUIRED STENOSIS AND ATRESIA. 

Remember that stenosis means narrowing of the 
vagina by cicatricial contraction; atresia means ob- 
literation of the canal by the agglutination of ap- 
posed granulating surfaces. 

Remember that this condition may occur at any 
part of the vagina or may involve the entire canal. 

Remember that lacerations from labor, or for- 
eign bodies — such as badly fitting pessaries — are 
frequent causes, and from any cause, if enough tis- 
sue has been involved, may produce enough scar 
tissue during the healing process to cause stenosis. 

Remember that sometimes a faulty operative 
technic, in the repair of lacerations, or excision of 
labia, may narrow the vagina and cause stricture. ' 

Remember that often the symptoms are not pro- 
nounced until there is sufficient obstruction to pre- 
vent tiie escape of vaginal discharges or menstrual 
blood, or to interfere with sexual intercourse. 

Remember that coitus is only partially interfered 
with when the obstruction is situated in the upper 

78 



DISEASES OF THE VAGINA. 79 

part of the vagina and when there is no tender- 
ness in the parts. 

The obstruction will be encountered by the ex- 
amining finger at the site of stenosis, whether near 
the vulva or high in the vagina. 

If there is a complete stenosis of the vagina, the 
patient should be examined by the rectoabdominal 
route to ascertain the size, position, and condition 
of the uterus and appendages, or if there is any 
retained menstrual fluid in any part of the canal. 
If so, the upper part of the vagina or uterus, or 
both, will be distended and have a rather boggy 
feel. This fluid may have partially escaped through 
the Fallopian tubes into the peritoneal cavity, giv- 
ing more or less peritoneal irritation. 

Treatment. — Do not attempt any stretching or 
operative work for this trouble with local anesthe- 
sia. A general anesthetic must be given. 

With the patient in the dorsal position, do not 
attempt much cutting, if there is stenosis, without a 
sound in the bladder and the finger of the assistant 
in the rectum to use as guides, thereby protecting 
these organs from injury. 

Remember that in atresia a piece of gauze over 
finger tips will aid materially in dividing adhesions. 
All raw surfaces should be covered as much a.s pos- 
sible, and if this cannot be completely done, the 
daily application of carbolized vaselin must be em- 
ployed to prevent the raw surfaces from agglutina- 
ting. 



80 GOLDEN RULES OF GYNECOLOGY. 

Do not leave ragged adhesive bands; they should 
be cut close to the vaginal wall, and a suture placed 
across to cover raw edges. 

Bear in mind that sutures should be placed in the 
long axis or parallel with the vagina; if introduced 
transversely, particularly if considerable sewing is 
done, they have a tendency to narrow the canal. 

Remember that, if there has been much deep scar- 
ring, it will be impossible to stretch this tough 
fibrous tissue and it may become necessary to make 
several deep parallel incisions; the mucosa should 
be dissected loose from the deeper tissues to allow 
the cut mucous surfaces to be reunited by sutures as 
far as possible; the mucosa, even if thick and 
made up largely of scar tissue, will allow of con- 
siderable stretching. All bleeding surfaces and 
points in the deeper tissues must be controlled first, 
and finally, it may become necessary to use a glass 
or rubber plug to keep the parts dilated to a suf- 
ficient caliber until healing has been perfect. 

Acquired stenosis must not be confounded with 
the congenital variety, referred to in a previous 
chapter (Adhesions of the Labia, Chap. I, page 62), 
where the trouble is due largely to a lack of develop- 
ment instead of a diseased or pathological condi- 
tion. 

Remember that these patients suffer much pain 
for the first three or four days and will require 
opiates, etc., as indicated. There will be some vag- 
inal discharge, which must be kept clean, if a 



DISEASES OF THE VAGINA. 81 

•plug is used that will have to be removed daily. 
Saline douches, or, if there is some odor, formalde- 
hyd douches (gj of formaldehyd to Oiv of warm 
water) should be used once or twice daily. 

CYSTOCELE AND RECTOCELE. 

Eemember that lacerations of the peritoneum may 
destroy the retaining power of the pelvic floor ; there 
will be a gradual prolapse of the anterior and pos- 
terior vaginal walls. If it is of the anterior vaginal 
wall containing the bladder, it is known as anterior 
colpocele or cystocele; if it is of the posterior vagi- 
nal wall, it is known as posterior colpocele or rec- 
tocele. As a rule, both are found prolapsed in some 
degree in the same individual. 

Keep in mind that, with a deep anterior and pos- 
terior laceration, the daily efforts and straining at 
stool and micturition will eventually force the pos- 
terior wall of the bladder and the anterior wall of 
the rectum out, until they present as pouches with 
the vaginal mucous membrane for a covering. 

Eemember that this is a condition found in the 
woman who has borne children. 

It is always associated with prolapse of the uterus 
in the second or third degree, but remember that we 
may have cystocele or rectocele, or both, without the 
uterine prolapse. 

There may be considerable sagging of the bladder 
without any well-defined symptoms; but as a rule, 
there is more or less vesical irritation from the great 



82 GOLDEN EXILES OF GYNECOLOGY. 

' effort or inability to entirely empty the bladder ; the 
urine has to travel up hill, as it were, and in exag- 
gerated cases the patient will be obliged to take her 
hands and elevate the bladder into the vagina in 
order to expel the urine. 

Keep in mind that in this class of cases there will 
always be residual urine, which becomes alkaline in 
reaction, loaded with sediment, and is the cause of 
much vesical irritation. 

While there should be no difficulty in making a 
diagnosis of cystocele, yet it is well to remember 
that if there is bulging of any character from the 
vagina the patient will speak of the condition as 
* ^falling of the womb," and while there may be some 
degree of prolapse, yet the protruding tumor is in 
reality the bladder. 

Remember that, if there be a doubt, a curved 
sound may be introduced, when the end will be found 
to travel to the lowest point of the pouch, where it 
can be plainly felt through the tissues with the fin- 
gers. 

Remember that the vagina may be filled with 
sterile water, when the tumor may be observed as it 
enlarges and diminishes in size when the water is 
syphoned away. 

Remember that a vaginal hernia, if it contains in- 
testine, is tympanitic on percussion, gives the char- 
acteristic impulses on coughing, and when returned 
the bladder will be found not displaced. A sound 
may be introduced into the bladder while the tumor 



DISEASES OF THE VAGINA. 83 

is down, when it will be found that it has no con- 
nection with the bladder. 

Remember that vaginal tumors do not vary in size 
or impulse upon coughing, straining, or filling of the 
bladder; they are stationary and cannot be returned, 
as can hernia or prolapse of the bladder. 

Remember that cystocele and rectocele usually oc- 
cur together and are due to the same cause : viz., an- 
terior and posterior perineal lacerations. 

Symptoms. — Remember that with the general loss 
of tone, with sagging of practically all the pelvic 
viscera, there will be a feeling of fulness and weight 
in the pelvis; legs and back tire and ache. Consti- 
pation and difficulty in defecation — the force of the 
bowel contents — cause the anterior rectal wall to 
bulge out of vagina, and this has to be held back 
with the hand or fingers of the patient to make 
defecation possible. Autointoxication follows con- 
stipation, gastrointestinal disturbances, and head- 
aches. 

Diagnosis. — The diagnosis of rectocele is not a 
difficult matter. With the unmistakable perineal 
laceration in view, there is more or less bulging of 
the posterior vaginal wall; by introducing the index 
finger into the rectum, it can be hooked around, and 
the end brought into the vaginal pouch, revealing a 
relaxed anterior rectal wall with the tissue very thin 
between the finger in rectum and the other hand 
with which the pouch can be held. 

Treatment. — Remember that the treatment for 



84 GOLDEIT KULES OF GYNECOLOGY. 

cystocele or rectocele must always be radical if a 
cure is desired; local palliative treatment consists of 
an effort to keep the parts as well up as possible and 
by symptomatic treatment to make the patient as 
nearly comfortable as possible. 

These patients wear pessaries with difficulty ; they 
are very difficult to retain, and if large enough to 
remain within the vagina, produce pressure pain and 
often increase the bladder symptoms. 

If the uterus is prolapsed, a cup-and-stem pessary 
with an elastic T-bandage may be tolerated and worn 
with some degree of relief. 

Tampons of iodin and glycerin, or tannic acid and 
glycerin, help to relieve congestion, and by the as- 
tringent effect help to retain the bladder within the 
pelvis. 

Eemember that some benefit may be derived from 
wearing clothing that does not cause constriction 
around the waist; to keep off feet as much as possi- 
ble and only do very light work, if aijy at all; the 
bowels should be moved daily with salines, and the 
bladder emptied every four to six hours: 

Eemember that any other internal treatment can 
only be of benefit to relieve distressing symptoms as 
they arise. 

Eadical Treatment. — When there is sufficient re- 
laxation and prolapse of the anterior vaginal wall 
to require operation, this should be taken care of 
at the same time that the posterior perineal tear is 
repaired. 



DISEASES OF THE VAGINA. 85 

Eemember, if there is mnch sagging, that it may 
be necessary to follow one of the various operations 
suggested for the relief of this condition. Hegar's 
operation, anterior colporrhaphy, consists in remov- 
ing strips of tissue from cervix up over vault of 
vagina, out to the vestibule, until a large elliptical 
area has been removed. The apices point to the ves- 
tibule and cervix; the lateral edges are two inches or 
more apart, so that a deep row of catgut sutures are 
first required, after which the lateral edges of the 
vaginal mucosa are brought together with chromic 
catgut, beginning at the cervix and finishing at the 
vestibule ; this narrows the vaginal vault and has the 
effect of pushing up both the uterus and bladder. If 
there is a cervical laceration, that too must be re- 
paired. 

Eemember that by repairing the posterior perineal 
laceration much is done to hold up both the uterus 
and bladder. 

For the cure of rectocele, repair of the perineum 
or perineorrhaphy must be done. 

It is needless to discuss today any operation on the 
perineum which is not founded on anatomical prin- 
ciples; the latter perfectly restores the perineum and 
vagina, while the denuding operations narrow the 
vagina and pucker the underlying tissues without 
any attempt at restoration to normal. 

One of the best operations devised at the present 
time has been worked out by Dr. Howard Hill, and 
is based on the normal anatomy of the perineum. It 



86 GOLDEN KULES OF GYNECOLOGY. 

is simple and can be done in fifteen or twenty min- 
utes; there is no destruction of tissue. 

Either a lateral incision along skin and mucous 
membrane line, or antero-posterior incision may be 
made. By blunt lateral dissection the anterior edges 
of the levator ani muscles may be felt and caught 
with small '^ tenaculum forceps." The two edges 
are brought together and held by two catgut sutures 
properly placed, so as not to impinge too much on 
the vaginal orifice; the lower suture should catch 
some of the fibers of the sphincter ani. Next, the 
fascia is closed with chromic catgut, and finally, the 
superficial opening closed with the same suture. 
The author now puts in two rather deep silkworm- 
gut sutures, after all the tissues have been closed to 
re-enforce the catgut sutures; these are removed in 
about ten or twelve days. 

Eemember that, if the cystocele and rectocele were 
very troublesome, and particularly if there was some 
uterine prolapse, the anterior and posterior perineal 
repair may not be sufficient to give perfect relief, 
and if the uterus pushes down very hard will finally 
force its way to the vulva. 

In these cases a combined laparotomy should be 
done, and the uterus raised out of the pielvis and 
held in place by some operation of shortening the 
round ligaments. The author prefers the Cros.sen 
modification of the Gilliam-Ferguson operation. 
The posterior wall of the bladder being attached to 
the uterus, the anterior wall of the rectum, as well. 



DISEASES OF THE VAGINA. 87 

is attached to the uterus behind; hence, when the 
uterus is raised by shortening the round ligaments, 
the bladder and rectum are also raised and held in 
place. 

Now remember that, if the vaginal prolapse is 
very great and the uterus presents itself outside 
the vulva, the additional operation of shortening 
the round ligaments will not be sufficient. These 
women have given birth to several children and are 
usually near or past the child-bearing period. 

Eemember, then, that in these extreme cases a 
more radical procedure is necessary. Excellent re- 
sults are obtained by raising the uterus out of the 
pelvis into the abdominal wound, closing the peri- 
toneal opening above and below, and sewing the 
sides to the uterus; the muscle and fascia are also 
brought around the uterus in the same manner. 
The point of thus fixing the abdominal wall to the 
uterus depends upon the degree of relaxation, and 
the uterus may be raised or lowered to suit the case 
before it is finally fixed. After the skin has been 
closed, the fundus rests in the fat between the skin 
and fascia. This precludes any further danger of 
prolapse. 

HERNIA. 

Eemember that a vaginal hernia starts either be- 
hind or in front of the broad ligaments. "When it 
starts behind it begins in the cul-de-sac of Douglas 
and descends between the rectum and vagina; then, 



88 GOLDEN KULES OF GYNECOLOGY. 

separating the fibers of tlie levator ani muscle, it 
appears either at the posterior part of the labium 
majus, or in the perineum. Starting in front of the 
broad ligament, it pushes the vesicouterine peri- 
toneal fold down between the vagina and bladder, 
and appears at the posterior part of the labium 
majus. 

Eemember that if located in the anterior or pos- 
terior wall of the vagina the size of the tumor in- 
creases on coughing or straining. 

Remember the gurgling sound so characteristic of 
the replacement of the contents of a hernial sac into 
the abdomen. 

Remember that cyst of the vulvovaginal gland or 
tumor of the labium is smooth and firm, and does 
not disappear on pressure, or is it influenced as to 
size by coughing or straining. 

Remember that a hernia has a doughy feel to the 
examining finger and is tympanitic on percussion. 

Treatment. — Remember that the reduction of the 
hernia is easily accomplished by first emptying the 
bladder and rectum, then placing the patient in 
the knee-chest position, and making steady pressure 
upon the tumor until the contents of the sac slip 
back. 

Remember that a hard-rubber ring pessary large 
enough to distend the canal may be used to control 
the hernia. The ring .should be as large as can be 
inserted and should be carried well up into the for- 
niees, the ring surrounding the cervix uteri. 



DISEASES OF THE VAGINA. 89 

Treatment of Vaginolabial Hernia. — Eemember 
that this variety of hernia occurs more frequently 
anteriorly to the broad ligament than it does pos- 
teriorly. It can usually be replaced with the patient 
in the knee-chest position, except in case of strangu- 
lation. The operative treatment is practically the 
same as for hernia elsewhere. 

Vaginal Eoute. — If the vagina is roomy and the 
surgeon can demonstrate to his satisfaction that he 
can reach and at)proximate the tissues, this route 
may be chosen. The overlying tissues are incised 
and dissected away until the sac is isolated. It 
should be opened, and the contents well returned; 
after which the sac should be loosened from the 
fascia, surplus cut off and closed. Then the fascia is 
closed outside of sac, and finally the vaginal opening. 

Dangers. — Great care must be exercised so as not 
to injure the bladder; great difficulty may be encoun- 
tered in keeping back abdominal contents while sew- 
ing up peritoneum; great caution must be exercised 
during the entire operation lest the bladder is punc- 
tured by the needle. 

Eemember that, if there is strangulation, the vagi- 
na] route is out of the question. 

Abdominal Eoute. — This is by far preferable to 
the vaginal route. Here one can get all the tissues 
out of the way and protect the bladder, closing the 
hernial opening, and then inverting and closing the 
peritoneal opening after the excess of sac has been 
trimmed off. 



90 GOLDEN KULES OF GYIsrECOLOGY. 

VAGINITIS. 

Eemember tliat inflammation of tlie vagina is 
nearly always associated with and is frequently tlie 
canse of vulvitis. It can usnally be traced to some 
infection. 

Eemember that, while the normal acid secretion 
of the vagina is a germicide under ordinary condi- 
tions, yet, in cases of pelvic tumors, displacements, 
or inflammation of any portion of the genital tract, 
there will be sufficient alteration of the vaginal se- 
cretion to overcome its germicidal action. 

Eemember that this is also true in anemia, tuber- 
culosisj or any of the debilitating diseases when re- 
sistance generally is below par. 

Simple vaginitis means an irritation and conges- 
tion (which has not quite reached the point of in- 
flammation) of the vaginal mucous membrane, with 
an increase of the mucous secretion. No doubt these 
cases owe their origin to the debilitating diseases 
just mentioned, and the treatment must be general 
as well as local; and directed to remove the cause. 

Eemember that while this is a case of simple 
vaginitis the patient is not proof against infection. 
In fact, it is quite the reverse; with her entire sys- 
tem debilitated from disease, her resistance lowered, 
and the vaginal mucous membrane irritated and 
congested, a severe infection might ensue. 

Eemember that in the large cities at least, gonor- 
rhea is doubtless responsible for the greatest num- 



DISEASES OF THE VAGINA. 91 

ber; but remember that Tinsterilized instruments 
used by examiner, or a douche-nozzle that has been 
used by another person, may carry the gonococci, 
streptococci, staphylococci, or the colon bacilli into 
the vagina; pessaries that are not sterile or are 
poorly fitting may produce an irritation; or the use 
of the various antiseptic tablets for the prevention 
of pregnancy may be responsible. 

Eemember that uterine discharges from acute sep- 
tic endometritis will cause vaginitis; this rarely oc- 
curs from a chronic discharge. It should be remem- 
bered, however, that, when a patient with a chronic 
discharge is confined in bed from any cause, a cleans- 
ing douche should be given once daily; otherwise 
the discharges will be retained in the vagina, where 
they decompose and cause irritation. 

Eemember that frequent sexual intercourse or a 
great disproportion between the male and female is 
sometimes responsible for vaginitis. 

Eemember that at first the vaginal walls are red 
and hot from acute congestion. 

Eemember that early in the disease there is but 
little discharge but later the parts may become 
bathed in serum and pus. 

• Eemember that in neglected gonorrheal vaginitis 
the discharges are so irritating that there will be 
found a large area around the vulva extending out 
on the thighs and down around the anus, where the 
skin will be red and edematous. Paiiiful fissures 
and erosions follow, or, from continued irritation 



92 GOLDEN KTJLES OF GYNECOLOGYc 

and stimulation of the skin, numerous papillary 
growths develop. 

Eemember that in the acute cases pain is severe, 
particularly upon manipulation, and if there is also 
vulvitis, it is sometimes difficult or impossible for 
the patient to walk or to be on her feet. 

Eemember that in chronic vaginitis the discharges 
persist, loaded with epithelium, exfoliated from the 
vaginal walls. This leaves the papillse exposed and 
swollen, on account of denudation of their epithelial 
covering, giving a rough feeling, or the condition 
known as granular vaginitis. 

Symptoms. — The patients have first a feeling or 
sensation of heat and dryness in the vagina, with a 
slight itching at the vulvar outlet. 

Eemember that, as a rule, these patients do not 
manifest any general systemic reaction, although it 
stands to reason that there is some inclination to 
febrile disturbance; the greatest discomfort, no 
doubt, is the sensation of fulness and heat communi- 
cated to the rectum and bladder. A frequent desire 
to urinate may be felt. 

Eemember that the discharge is not great, and 
sometimes absent, in the beginning; however, after 
a few days, it becomes profuse and purulent. 

Diagnosis. — Examine the external urinary meatus, 
which is often visibly affected and bathed in pus; 
if so, it may be gonorrheal infection. 

Eemember that all vaginal discharges should be 
submitted to a pathologist for examination. 



DISEASES OF THE VAGINA. 93 

Treatment. — Rest is one of the best agents in the 
treatment of acute inflammatory diseases, and dur- 
ing the acute stage of vaginitis it should be enforced 
unless it is absolutely necessary for the patient to 
work daily to earn her living. Do not be unreason- 
able; some women are obliged to support a whole 
family, and it is a serious loss if they are obliged to 
be away from their work. 

Remember that, if the pain is sufficient or the an- 
noyance of burning and itching great enough to re- 
quire a sedative, it must not be administered in the 
form of a rectal suppository; nor should an enema 
be given during the acute stage, for fear that the 
infection might be carried into the rectum. Have 
the patients take long copious hot douches three or 
four times a day, or as often as their duties will per- 
mit. To three or four quarts of hot water may be 
added one teaspoonful of formaldehyd, 40 per cent, 
powdered borax, or boracic acid. Use local treat- 
ments every other day. Clean out vagina by use of 
a speculum and cotton pledgets squeezed from hot 
water; after this a thorough application of silver 
nitrate solution, 4 per cent, may be applied with a 
cotton swab over the entire vaginal and cervical .sur- 
faces. Do not use this too often; once or twice 
weekly may be sufficient; then place a tampon of 
some of the glycerin mixtures (preferably with 
ichthyol, 20 per cent) against the cervix, and instruct 
patient to leave it in place for eight or ten hours. 
After its removal a hot douche should be taken. 



94 GOLDEN RULES OF GYNECOLOGY. 

Remember that if tlie vagina and vnlva are too 
.sensitive to admit tlie nse of a speculnm hot douches 
must be relied upon until the acute symptoms sub- 
side or the tissues become more tolerant. 

Remember that constipation contributes to pelvic 
congestion and salines should be administered as 
often as indicated. 

Keep in mind the benefits derived from drinking 
plenty of water, and this is especially true when 
there is urethral or bladder complications. When 
there is considerable vesical disturbance use oil of 
wintergreen, 10 minims, four or five times daily; 
tincture of belladonna in 5-minim doses relieves 
vesicle irritation. 

When astringent powders are used instead of the 
solutions, boric acid, zinc oxid, calomel, or tannin 
are the best. Half an ounce of powder should be 
placed in the vaginal vault, and a dry tampon in- 
serted to hold it there. 

GRANULAR VAGINITIS. 

Remember that this is the most frequent form of 
vaginitis and the granular appearance of the mu- 
cous membrane is due to the inflammatory conges- 
tion of the papillaB. 

Remember that this form may result from simple 
or gonorrheal vaginitis. 

Remember that the patient complains of tender- 
ness with a feeling of pelvic fulness and a muco- 
purulent discharge. 



DISEASES OF THE VAGINA. 95 

Eemember that pruritus vulvae is a more or less 
constant symptom and eczematous eruption may oc- 
cur on tlie external genitalia. 

Eemember that the diagnosis is made by inspec- 
tion of the vaginal canal and this is best done with 
the patient in the knee-chest position. 

Eemember that this condition occurs sometimes 
during pregnancy and at its termination will disap- 
pear. 

Treatment. — Eemember that the bowels should 
be kept open with a mild laxative. 

The vagina should be douched daily with a gallon 
of hot salt solution, followed by a half gallon of 
bichlorid solution (1:4000), or a gallon of hot lysol 
solution, 2 per cent, may be used. 

When an astringent is needed nothing is better 
than a 5 per cent solution of silver nitrate painted 
over the granulations. 

A tampon saturated with a 25 per cent solution 
of argyrol, protargol 3 per cent, or boroglycerid, 
should be introduced and remain for twenty-four 
hours. 

Sometimes the application of sulphate of copper 
(gr. XXX to 5j) to the granulations will hasten a cure. 

SENILE VAGINITIS. 

Eemember that this is the change brought on by 
old age and is found in women who have passed the 
menopause. 

Eemember that the symptoms are, as a rule, not 



96 GOLDEN KULES OF GYNECOLOGY. 

pronounced. The patients complain of a tliin leu- 
corrlieal discharge, nsnally not profuse, and occa- 
sionally streaked with blood. 

Eemember that this discharge may be very irri- 
tating to the external genitalia and cause a pruritus 
or severe burning sensation. 

Remember that inspection reveals a mucous mem- 
brane that is smooth, atrophied, and covered with a 
scanty secretion. Various-sized spots of ecchymo.sis 
and superficial ulcerations are found scattered over 
the surface. 

Remember that adhesions are formed from con- 
tact between ulcerated surfaces and the vault, or 
even the canal may be obliterated in this manner. 

Treatment. — If the condition causes no annoy- 
ance to the patient, no treatment is needed, except 
a daily cleansing douche. 

When the ulcers are present and painful, they 
should be painted with a 5 per cent solution of silver 
nitrate. A hot antiseptic douche of one gallon 
should be taken daily. This may consist of a 2 per 
cent lysol solution, or bichlorid (1:6000), 

Whej*e adhesions do not interfere with secretions 
and are old and dense, they should be let alone. 
When recent, they are easily broken up. A tampon 
upon which some ointment has been spread should 
be inserted. Either of the following may be used: 
vaselin, zinc oxid ointment, to which is added 3 per 
cent phenol. This prevents the reforming of the ad- 
hesions. 



DISEASES OF THE VAGINA. 97 

CYSTS. 

Eemember that cysts are the most common form 
of neoplasms found in the vagina. While they 
are found usually in the anterior or po.sterior wall, 
they will be found occasionally in other portions of 
the canal. As a rule, they occur singly, and they 
grow very slowl}^ and require years to develop. 

Remember that the cyst is round and circum- 
scribed, as a rule, but exceptionally it may be 
pear-shaped and have a pedicle. 

Remember that if inflammation has not occurred 
the cyst is freely movable beneath the mucous mem- 
brane. 

Remember that the symptoms vary with the size 
and location of the cyst. Thus it may press upon 
the urethra and interfere with the voiding of the 
urine, or by pressure upon the bladder wall lessen 
its capacity, and thus cause frequent micturition. 

Remember that a cyst pressing upon the rectum 
causes a feeling of weight in the pelvis and produces 
constipation and hemorrhoids. 

It may be so located as to interfere with sexual 
intercourse by obstructing the entrance of the penis. 

Remember that a very important feature in diag- 
nosis is to demonstrate that the tumor is movable 
and not fixed to the wall of the vagina. This is done 
b}^ grasping the enlargement with the fingers and 
making traction in different directions in order to 
demonstrate by touch its connections. 



98 GOLDEN KULES OF GYNECOLOGY. 

Eemember tliat the combined rectovaginal touch 
must be used if the cyst is on the posterior wall. If 
the cyst is on the anterior wall, a sound may be 
passed into the bladder; and with the examining 
finger in the vagina counterpressure is made, and 
its connection established. 

Remember that a cyst located high near the cervix 
requires a general anesthetic, when the examining 
finger in the vagina may be met by counterpres.sure 
over the abdomen just above the symphysis. 

Remember that the cyst is tense, elastic, and is 
. usually circumscribed. Fluctuation can be detected 
in a large cyst. 

Remember that a cystocele is always located an- 
teriorly and increases in size by filling the bladder 
or in straining and in coughing, and disappears in 
the recumbent position. 

Remember that a rectocele is always located pos- 
teriorly, increases in size on coughing, disappears on 
pressure, and is only in the walls of the vagina and 
rectum between the examining finger in the vagina 
and the one in the rectum. 

Treatment. — Remember that the treatment is al- 
ways surgical and consists in removal of the entire 
sac. This is best accomplished with the patient 
under a general anesthetic. 

CANCER OF THE VAGINA.* 

Remember that it is rarely primary ; it is nearly al- 
ways secondary to cancer of the cervix. It may be 



DISEASES OF THE VAGINA. 99 

secondary to cancer of bladder, urethra, vulva, or 
lectum. 

Eemember that the cancer spreads rapidly by 
lymphatics and infiltration of the surrounding tis- 
sues. 

Eemember that hemorrhage and discharge are the 
characteristic symptoms. 

Eemember that in the beginning the hemorrhage 
is slight and may be first noticed after sexual inter- 
course or defecation, but that the hemorrhage be- 
comes more severe until eventually there is contin- 
uous loss of blood. 

Eemember that the discharge is watery and of- 
fensive early, but as ulceration and loss of tissue 
occur the discharge becomes bloody; pieces of tis- 
sue, pus, feces, and urine are found in it, and the 
odor is fetid. 

Eemember that pain is not an early .symptom and 
may be absent throughout the course of the disease. 
AYlien present it is felt in rectum, bladder, pelvis, or 
along the sciatic nerves. 

Eemember that the cancerous cachexia, loss of 
weight, and other constitutional s^miptoms found in 
malignancy elsewhere, are present, but occur late in 
the disease. 

Eemember that a specimen of the tissues should 
be sent to a pathologist early in the disease, if there 
is any question of doubt, for microscopic examina- 
tion to determine if the growth is malignant, whether 
carcinoma or sarcoma. 



100 GOLDEN KULES OF GYNECOLOGY. 

No physician at the present time should delay a 
diagnosis waiting for clinical symptoms to complete 
the picture of malignancy, because the hope of the 
patient rests on a very early diagnosis and the com- 
plete eradication of the trouble. 

Treatment. — Remember that primary cancer of 
the vagina is rather rare, and when such a condition 
is recognized, early and complete extirpation before 
it has spread to adjacent organs or involved the lym- 
phatics is indicated. 

Do not depend entirely upon the clean sweep with 
the knife around this dangerous growth; use the 
actual cautery over the edges and base after the 
growth has been removed. Heat has a retrograde 
influence upon the cancer cell and is one of the best 
agents we have at the present time, at least in cancer 
of the vagina and cervix. 

No effort should be made to close or approximate 
the edges after cauterization unless there is an ex- 
tensive surface uncovered, when it may become nec- 
essary to close the edges, leaving room for drainage 
between the stitches. This must be watched with 
the greatest care, and any evidence of return should 
call for another application of the cautery. 

GONORRHEA. 

Gonorrheal infection of the female genital organs 
has reached a stage where it is almost a universal 
calamity. 

It is such a common disease that it is regarded as 



DISEASES OF THE VAGINA. 101 

a joke by a great many of the laity, because they do 
not understand its viciousness, and possibly it is not 
met seriously enough by some physicians. 

Eemember that men can recover from it, although 
it often leaves the scars of battle. 

But keep keenly in mind that it is rare indeed for 
a woman to entirely recover from gonorrheal infec- 
tion, and that a large percentage of the women who 
come for operations are suffering with pelvic disease 
of gonorrheal origin. 

When we are thoroughly in sympathy with the 
young woman, with a year or two of married life, 
who has passed through a period of anguish and 
pain which she believes is a part of woman's married 
state and finally submits to an operation, which 
more than likely renders her unsexed; when we lis- 
ten to the lamentations of many good women who 
are childless and who would be willing to risk their 
lives to become mothers; when we have considered 
all their suffering, disappointments, and sorrow, we 
still fail to entirely comprehend the ravages of this 
disease. 

Our experience with this infection in women 
makes it loom up like a huge mountain, and other 
vices fade as the valley beside it. The time is at 
hand when physicians should be compelled by law 
to report all cases of gonorrhea that come under 
their treatment to the Boards of Health, and before 
the case is discharged as cured, the City or County 
pathologist should have specimens for examination, 



102 GOLDEN KULES OF GYNECOLOGY. 

and he should give a favorable report before the 
patient is discharged. 

Not until then can we hope to control and prevent 
the spread of this terrible disease. 

Remember that gonorrhea is an inflammation of the 
genital organs due to the gonococcus infection, and 
that, as a rule, it first attacks the vaginal mucous 
membrane — except in children, where it usually be- 
gins as a vulvitis — and the exterior mucous mem- 
brane of the cervix; it soon extends to the vulva and 
urethra and may reach the bladder; if not checked, 
it will extend to the cervical canal, cavity of the 
uterus, Fallopian tubes, and pelvic peritoneum. 

Remember that it is usually communicated from 
one person to another through sexual intercourse, 
although it may be communicated through the use 
of an infected towel or closet seat — such an explana- 
tion may be regarded with a little suspicion. We 
have known it to be transmitted from one woman 
to another by the promiscuous use of a douche-noz- 
zle. 

How children become infected is often a matter 
of much speculation. No doubt it is most frequently 
caused by close proximity with adults in sleeping in 
the same bed, the handling or bathing of genitals 
by nurse or mother who herself has gonorrhea, and 
whose fingers are contaminated by the germs. 

A little girl, eight years of age, was brought to 
our clinic by her mother for what proved to be a 



DISEASES OF THE VAGINA. 103 

gonorrheal vulvitis; when the inflammation began 
the child complained to her mother that her father 
(a drunkard) had been playing with her genitals; 
when he saw the condition of his child he became 
frightened and ran away; examination of the mother 
revealed that she also had gonorrhea. 

It is well to remember that gonorrhea in chil- 
dren is usually confined to the vulva and urethra; 
consequently with appropriate treatment a perfect 
cure may result without deeper involvement. 

Symptoms. — Eemember that in the newly married 
woman or girl there will be felt some irritation about 
the urethra and vulva a few days after intercourse. 
Urination becomes painful, being attended with 
smarting and burning. In a few days the vulva be- 
comes bathed with the discharge of pus, which is at- 
tended with considerable discomfort and distress 
in both the vagina and vulva; the vaginal mucous 
membrane will be found to be swollen and rather 
tender, and communicating to the examining finger 
a feeling of heat and roughness; if the urethra is 
pressed upon through the anterior vaginal wall, pus 
will often exude from the external meatus. 

Eemember that gonorrheal pus has a yellow- 
ish color during the acute stage and that the cloth- 
ing will bear the yellowish stain; in chronic gonor- 
rhea this is not always the case. 

Eemember that in the acute stage there will be a 
frequent desire to urinate and that urination will be 



104 GOLDEN KULES OF GYNECOLOGY. 

accompanied by pain and smarting, the discharge 
will be profuse, the external genitals will be red and 
swollen. 

Diagnosis. — Now keep in mind that gonorrhea in 
woman is one of the most serious infections that she 
may have and that a correct diagnosis is necessary, 
so that proper treatment may be instituted for a 
cure and to prevent complications if possible. 

Remember that vulvitis and vaginitis from any 
other infection, except gonorrheal, are seldom so 
acute right from the onset. It reaches its height in 
a week or ten days, and then, as a rule, begins to 
subside; the urethra is always involved, and it has 
been claimed that infection of the vulvovaginal 
glands makes the diagnosis of gonorrhea almo.st cer- 
tain. 

However, remember that inflammation of the vul- 
vovaginal glands, may take place from other infec- 
tions. 

Remember that in vaginitis from any other cause 
there is in all probability a history of some infection 
or opportunity for infection: e. g., abortion, labor, 
or instrumental manipulation. 

Do not be deceived into thinking that because the 
inflammation is not severe that it may not be gonor- 
rheal. 

Remember that gonorrheal attacks vary in sever- 
ity; in the young woman it may be severe; in the 
woman who has borne children and who has been 
subject to other onslaughts there is a more tolerant 



DISEASES OF THE VAGINA. 105 

mucous membrane. This is especially true where 
there has been a previous gonorrhea. 

Kemember that if there is the least room for doubt 
that the discharge should be submitted to a patholo- 
gist for examination. 

Remember that in a chronic case the gonococci' 
may not be found in the first microscopic examina- 
tion; the pus may not have been taken from the 
right place, and if there is clinical evidence of the 
disease it should be tried again. Pus pressed from 
the urethra or taken from the upper part of the va- 
gina or cervix is likely to demonstrate the gonococci. 

Remember that there are diplo cocci that take the 
same stain as the gonococci, and yet this patient has 
never had any of the clinical symptoms of acute 
gonorrhea ; this would prove very embarrassing and 
emphasizes the necessity of employing an expert 
pathologist, who is thoroughly familiar with these 
conditions. Such difficulties could only obtain, how- 
ever, in chronic cases, where for some reason or 
another a definite history of an acute attack could 
not be obtained. 

Treatment. — Keep in mind that in a Known case 
of gonorrhea our ultimate desire should be a com- 
plete cure without extension of the infection to the 
uterus. Fallopian tubes, pelvic peritoneum, and 
ovaries. 

Therefore, it is well to keep in mind that, if the 
inflammation fortunately seems to involve only the 
vulva, the vagina should not be tampered with, and 



106 GOLDEN^ EULES OF GYNECOLOGY. 

if the vagina is tlie seat of inflammation, not to med- 
dle with the interior of the cervical canal, lest the 
infection, which by natural selection has a tendency 
to penetrate deeper, is forced into the cervix against 
the natural defense. 

Eemember that the cervix furnishes a considera- 
ble amount of resistance against the entrance of 
infection. The canal is usually contracted, irregu- 
lar on its surface, and closed by a plug of mucus. 
The more patulous the cervix, the more readily in- 
fection may enter; hence after parturition, abortion, 
or just following the menstrual period are favorable 
times for extension. 

Eemember that in the girl or young woman whose 
hymen is not ruptured it is possible to keep the in- 
fection confined to the vulva and effect a cure with- 
out further extension. 

Do not advise vaginal douches in these cases. 

The doctor himself should, if possible, see and 
treat these cases daily; the vulva should be thor- 
oughly cleansed (a 1:5000 bichlorid solution may 
be used) with plain warm water. After whick an 
application of some of the- various gonococcicides 
may be used. Argyrol in a 10 to 25 per cent solu- 
tion does well in some; this is particularly useful in 
the urinary meatus after the pus has been thor- 
oughly cleaned out ; avoid the meatus, however, dur- 
ing the acute stage. 

Protargol 4 or 5 per cent and silver nitrate 2 to 4 
per cent have given us the best results, and unless 



DISEASES OF THE VAGINA. 107 

used strong enough to burn have no objectionable 
features. If the patient is a child, instruct mother 
or nurse, or if a grown woman teach her the neces- 
sity of constantly wearing a sanitary gauze pad held 
with a T-bandage. This should be changed as often 
as it becomes soiled. The patient should have a^ 
dusting powder for this pad, of zinc stearate, boracic 
acid, or berated talcum powder, which keeps the 

parts moderately dry, and prevents irritation. 

* 

Do not let the patient come to your office during 
the acute period if it is possible for her to stay at 
home. 

Remember that rest in bed at this time is a very 
important part of the treatment. Walking causes 
friction and more irritation of the inflamed parts. 

If the discharge is copious the patient may bathe 
herself two or three times daily with a weak, warm 
solution of bichlorid. 

If there is urethral inflammation with a frequent 
desire to urinate, urotropin, santal oil, or oil of win- 
tergreen may be used to advantage. We have found 
the following prescription useful: 

I^ Tincturag belladonnse 3 j 

Soclii beiizoatis 3 j 

Olei gaultherise ( true ) 3 iss 

Fluidextracti tritici 3 iv 

Elixiris aromatici q. s. ad S iv 

Mi see. 

Sig. : Shake. Teaspoonful in water every 2, 3, or 4 liours. 

Eemember if the vagina is infected that practi- 
cally the same treatment may be followed, except 



108 GOLDEN KULES OF GYNECOLOGY, 

that, in connection with the external douching, a 
vaginal douche should be taken every four to six 
hours during the acute period. Be careful in advis- 
ing bichlorid douches, lest they may be used too 
strong. 

Eemember that it is safer to have a bichlorid so- 
lution made up for the patient, with directions to 
use a teaspoonful to two quarts of warm water, than 
to trust her with bichlorid tablets. 

Do. not advise bichlorid douches taken several 
times daily. Once daily of a weak solution is 
enough. The other douches might be made with 3 j 
of zinc sulphate to two quarts of water. Boracic 
acid 3 j to two quarts of water, or saline solution, 
may be sufficient for cleansing purposes, with the 
one douche daily of the bichlorid solution. 

Eemember that as the symptoms begin to .subside 
the treatment should be less vigorous. 

Do not fail to emphasize at any time the danger 
of carrying the infection to others and the very great 
danger of eye infection. 

After three or four weeks of treatment the patient 
may be apparently well. Do not, however, dis- 
charge her as well without making several micro- 
scopic examinations' of the secretions. Even if 
these examinations are negative, the patient should 
be kept under observation for several weeks or 
months for the appearance of unfavorable .symp- 
toms. 

Eemember that the day of serum and vaccine 



DISEASES OF THE VAGINA. 109 

therapy is here, and here to stay. It can do no harm 
to administer four or five doses of Neisser vaccine 
^ve or six days apart to this patient as a finale of the 
treatment, and it may save her from lapsing into 
the chronic stage with sad complications. It has 
proved quite effectual in our hands, just at the de- 
cline from the acute stage, as well as in chronic 
gonorrhea. 

Eemember that even after the discharge has 
ceased it is quite a safeguard to paint around and 
over the cervix with tincture of iodin. This should 
be done three or four times, about a week apart. 

Treatment of Chronic Gonorrhea. — It is such a 
well-known fact that gonorrheal infection persists 
indefinitely, that a physician should not dare dismiss 
his case as cured until careful and repeated micro- 
scopic examinations fail to reveal the micro-organ- 
isms ; the infection may be found in the urethra, the 
vulva, vaginal ducts and glands, Skene's ducts, in 
the mucous membrane folds in the vagina, in the 
cervical canal, or in the uterus and Fallopian tubes. 

This patient should call at her physician's office 
two or three times a week. The urethra, glands, 
ducts, mucous membrane folds, and cervix should be 
thoroughly inspected and cleansed; a thorough ap- 
plication of 25 per cent solution of argyrol should be 
made, and a tampon of ichthyol, 10 per cent, with 
glycerin, inserted. Some prefer iodin 5 per cent and 
glycerin. 

Eemember that especial care must be given to the 



110 GOLDEN EULES OF GYNECOLOGY. 

ducts of the vulvovaginal glands and Skene's ducts; 
an effort must be made to penetrate them with the 
gonococcicide used. If the vulvovaginal glands sup- 
purate, they have to be enucleated, or incised, and 
the walls curetted away, after which the cavity is 
packed with gauze and allowed to heal by granula- 
tion. A general anesthetic is required. 

Eemember that if the wall of the gland is not 
thoroughly removed a suppurating sinus may re- 
main, requiring a subsequent operation. A thor- 
ough application of equal parts of carbolic acid and 
tincture of iodin to the cavity after curettage is 
splendid treatment. The packing should be re- 
moved every other day, and new packing replaced. 
An occasional stimulating application of tincture of 
iodin to the closing cavity is good practice. 

Let it be emphasized that, during this treatment, 
the gonorrheal vaccine should be administered every 
five to seven days. 

Now, if the uterine discharge persists, and if upon 
careful bimanual examination no tubal involvement 
is found, something must be done to facilitate cer- 
vical and uterine drainage, and save if possible the 
extension to the Fallopian tubes and peritoneum. 

Keep in mind that in such a case, if it cannot be 
cured, it will extend sooner or later. 

Under an anesthetic, the cervix should be well 
dilated, and the cavity of the uterus thoroughly 
cleansed by careful curettage, after which the whole 
surface should receive an application of equal parts 



DISEASES OF THE VAGINA. Ill 

of carbolic acid and tincture of iodin. A tape of 
iodoform is passed into the uterus to favor drainage 
and to prevent a too rapid contraction of the cervix. 
This is removed in two or three days. The treat- 
ment should be followed by hot douches to prevent 
an acute inflammation. 



CHAPTER IV. 
DISEASES OF THE UTERUS. 

POSTERIOR DISPLACEMENT. 

Remember that the uterus lies between the bladder 
and rectum above the vagina and below the ab- 
dominal cavity. 

Remember that the long axis of the uterus forms 
a right angle with the long axis of the vagina. 

Remember that, normally, the uterus is slightly 
anteflexed, with the concavity -forward. The an- 
terior surface rests upon the bladder, while the 
cervix points backward toward the coccyx. 

Remember that, normally, the uterus is freely 
movable; that a full bladder pushes it backward, or 
forward by a full rectum; that it moves up and down 
with respiration. 

Remember that the pressure from above, normally, 
is exerted on the fundus and the posterior portion of 
the uterus. 

Remember that, normally, the abdominal viscera 
exert their pressure upon the posterior surface, thus 
forcing the uterus forward upon the bladder. 

Remember that the question of displacement often 
becomes important in medicolegal affairs, because of 

112 



DISEASES OF THE UTEKUS. 113 

claims that a fall or jar causes a sudden and per- 
manent backward displacement; but it is extremely 
doubtful if displacement is ever caused in this man- 
ner, and probably the patient had the displacement 
but did not become aware of it until after receiving 
an injury. 

Eemember ■ that a displaced uterus will interfere 
with the venous blood flow, causing passive con- 
gestion of the organ and adnexa. This in turn pro- 
duces varicosities of the blood-vessels of the broad 
ligaments, and causes degeneration processes to oc- 
cur in the ovary and tubes. 

Eemember that menstruation will be profuse, due 
to the congested condition, but not all patients suffer 
pain. 

Eemember that backache in the sacral region, 
leucorrhea, constipation, headache, and often bladder 
irritation complete the category. 

Eemember that a uterine fibroid in the posterior 
wall is more nearly round in shape and harder in 
consistency than a displaced uterine fundus. 

Eemember that, as a rule, the cervix is displaced 
forward, striking the anterior vaginal wall, and it 
is on a line parallel with the vagina and lower down 
than normally. 

Eemember that during the puerperium, when the 
uterus is large and soft, the ligaments are relaxed, 
and the patient is lying on her back, all the condi- 
tions favoring retroversion are present. 

Eemember that subinvolution, following labor or 



114 GOLDEN RULES OF GYNECOLOGY. 

miscarriage, is a very frequent cause of displace- 
ment. 

Eemember tliat tight abdominal binders, or strictly 
confining the patient to the dorsal position, will 
often cause a retroversion. 

Eemember that nervous symptoms frequently oc- 
cur, and neurasthenia is the most common. There 
is a tired feeling and an utter lack of desire to exert 
oneself. 

Eemember that sterility is common in retrodis- 
placement, due to the complicating endometritis and 
the malposition of the cervix, thus interfering with 
the entrance of the spermatozoa. 

Eemember that it is only by a physical exami- 
nation that a diagnosis can be made. In making a 
bimanual examination, the po.sition of the cervix 
will be an indication of the position of the uterine 
body. If the cervix lies in its normal position, point- 
ing downward and backward toward the second 
sacral vertebra, the body of the uterus is likely to 
be in its normal po.sition or anteflexed. 

Eemember that no clinical syndrome will enable 
you to make a diagnosis, because of the great va- 
riations in intensity and character, and it is only by 
a physical examination that the condition may be 
diagnosed. 

Eemember that a physical examination is made 
with the patient in the dorsal position, the index 
finger of the left hand being introduced into the 
vagina. The position of the cervix is first; ^^- 



DISEASES OF THE UTEEUS. 115 

termined, whether lower in the vagina than normal, 
and pointing forward instead of backward toward 
the coccyx. 

The next step is the locating of the fundus. Nor- 
mally it is found anteriorly, and it should be .sought 
for in this locality. Push the index finger into the 
anterior cul-de-sac of the vagina, and at the same 
time make counterpressure on the abdominal wall 
immediately above the symphysis pubis with the 
fingers of the free hand. The fundus can be easily 
felt between the fingers of the two hands, if it is in 
its normal position. 

If the uterus be not found anteriorly, it should be 
sought for posteriorly by carrying the internal finger 
up into the posterior cul-de-sac; at the same time 
counterpressure is made upon the abdominal wall by 
pushing the structures down along the curve of the 
sacrum by the fingers of the external hand. The 
fundus may thus be caught between the fingers of 
the two hands and recognized by its outline. With 
continued counterpressure with the external hand 
the tip of the internal finger is passed slowly over 
the posterior surface of the uterus from the fundus 
to the cervix. If the cervix and the fundus lie in a 
straight line, then the uterus is retro verted; but 
should the line be convex, then it is a retroflexed 
^iterus. 

Eemember that in- a retroflexion the cervical canal 
may point in the normal direction but the fundus is 
bent backward so that the fundus and the cervix are 



116 GOLDEN EULES OF GYNECOLOGY. 

connected by a curved line whose concavity points 
downward. 

Eemember that a retrodisplacement mnst be dif- 
ferentiated from a fibroid on the posterior uterine 
wall. This is readily done by locating the fundus 
anteriorly and the cervix, normal in position in 
case of fibroid. 

Eemember that a tubo-ovarian mass lying behind 
the uterus is differentiated by the clinical history 
and by passing the uterine sound and demonstrating 
the position of the uterus with reference to the mass. 

Eemember that the determination of the location 
of the uterine fundus is always the most important 
differential point in diagnosticating uterine displace- 
ments. 

Treatment. — Eemember that the length of time 
displacement has existed is of great importance, 
because in a displacement existing for one year or 
more the tissue changes in the uterine support are 
permanent and palliative treatment will accomplish 
nothing. 

Eemember that in treating recent cases the follow- 
ing must be considered: 

1. Eemoval of the cause. 

2. Eeplacement of the uterus. 

3. Eetaining the uterus in normal position. 

4. Eeduction of the size of the uterus and stimu- 
lation of its ligaments. 

5. Eegulation of hygiene and general treatment. 
Eemember that the removal of the cause fre- 



DISEASES OF THE UTEKUS. 117 

quently consists of repair of tears in either pelvic 
floor, or cervix. In cases of chronic endometritis 
the uterus should be curetted. 

Eemember that there are two methods by which 
the uterus may be replaced. They are the bimanual 
method of replacement and replacement by the 
knee-chest position. 

Eemember that the bimanual method of replace- 
ment is very difficult in fat or muscular women. 

Eemember that the bladder and rectum must be 
emptied before attempting the bimanual method of 
replacement. 

Eemember that the following is the technic for the 
bimanual method: 

1. The clothing is loosened, and the patient, is put 
in the dorsal po.sition. 

2. The index and the middle fingers of the left 
hand are introduced into the vagina into the pos- 
terior cul-de-sac, and the fundus of the uterus is 
pushed upward to the promontory of the sacrum. 

3. When the fundus is on a level with the promon- 
tory, the fingers of the right hand push the abdom- 
inal wall behind the uterus, thus holding the uterus 
while the internal fingers are placed against the an- 
terior lip of the cervix and push it upward and back- 
ward. 

4. While the cervix is pushed upward and back- 
ward, the external hand pulls the uterine fundus 
forward into position. 

Eeplacement by the knee-chest position is usually 



118 GOLDEN" EULES OP GYiq-ECOLOGY. 

the best method, because when the vagina walls are 
separated air rushes in and balloons out the vagina, 
which causes the uterus to gravitate to its normal 
position. 

Eemember that the bladder and rectum .should be 
empty and the clothing loosened. 

The patient is placed in the knee-chest position,' 
a speculum introduced into the vagina, and the per- 
ineum well retracted, when the uterus will drop for- 
ward into the normal position. Should the uterus 
not fall forward at once, the anterior lip of the cer- 
vix should be caught with a forceps and pulled for- 
ward so that the uterus will swing clear of the sacral 
promontory. 

Eemember that any or all these methods will be 
ineffectual if the uterus is bound down by adhe- 
sions; sometimes the uterus itself may be free from 
adhesions and can be more or less perfectly brought 
forward to its normal anteflexed position, but owing 
to prolapsed tubes or ovaries, bound down by in- 
flammatory adhesions, the uterus will drop back to 
the posterior cul-de-sac soon after being released by 
the hands, or when the patient changes her position 
from the knee-chest to the dorsal or upright. 

A ball of absorbent cotton held in grasp of dress- 
ing forceps may be passed into the posterior fornix 
and against the posterior uterine wall, and pressed 
upward while the cervix is pulled down toward the 
vaginal outlet. 



DISEASES OF THE UTEEUS. 119 

Eemember that the uterns, after being replaced, 
must be held in position for a variable time, and this 
is accomplished by the use of the pessary. 

Eemember that a pessary must fit properly or it 
will be harmful. For instance, if it holds the uterus 
above or below its normal level, it obstructs the 
circulation and causes pelvic congestion. This 
trouble may be overcome by changing the length 
and angle of the posterior curve. A long, sharp 
curve holds the uterus higher than a short and less 
acute. Or, as the pessary is supported in front by 
the pubic rami, if the anterior curve is such that the 
pressure falls upon the neck of the bladder or the 
urethra, it must be changed. 

Eemember that a properly fitting pessary causes 
no pain and doe.s not interfere with sexual inter- 
course. 

Don't neglect a warm soapsuds douche weekly, but 
never use salt solution, as it causes incrustations to 
form on the pessary and by irritation of the parts 
causes inflammation. Don't neglect a weekly ex- 
amination in case of pregnancy, and at the begin- 
ning of the fourth month the pessary should be re- 
moved. 

Don't neglect to examine the patient in the erect 
position after introducing a pessary, to determine 
whether or not it fits properly. The examiner's fin- 
gers should pass between the vagina and the pes- 
sary at all points, the posterior cul-de-sac should be 



120 GOLDEN EULES OF GYNECOLOGY. 

taut, and the respiratory movement of the uterus 
should be felt. 

Remember that the method of introducing the pes- 
sary is as follows : The patient is placed in the dor- 
sal position; with the thumb and index finger of the 
left hand separate the labia; the pessary is held by 
the anterior bar between the thumb and index finger 
of the right hand, and the posterior bar is inserted 
in the transverse diameter of the vagina; push the 
pessary downward and backward along the pelvic 
curve until the posterior bar lies close against the 
anterior cervical lip. Now introduce the index fin- 
ger of the left hand into the vagina below the an- 
terior bar of the pessary until it presses against the 
posterior bar. The posterior bar is then pushed 
downward and backward until it is pressed behind 
the cervix. 

Remember that a routine course of treatment 
should be followed to cure the subinvolution of the 
pelvic organs. This is best carried out by the use 
of a vaginal douche of hot water and the introduc- 
tion every other day of a tampon of cotton-wool sat- 
urated with a 25 per cent solution of ichthyol in 
glycerin. 

A good general tonic should be administered, and 
the clothing kept loose. The patient should take 
light outdoor exercise. 

The following is probably the best depletory that 
can be applied to the vaginal vault. It causes no 
pain and is antiseptic. It is made as follows: 



DISEASES OF THE UTEEUS. 121 

IJ Glycerin! 3 viij 

Magnesii sulphatis « 3v 

Phenolis 3 ss 

Misce. 

Heat till all is dissolved forming a clear solution. No water 
is to be used. 

To this ichthyol or, in case an astringent is 
needed, zinc sulphate may be added. Ganze, or bet- 
ter, wool, saturated with the above and used as a 
tampon, will give perfect satisfaction as a deple- 
tory. 

Eemember that in chronic cases of long-standing 
or in cases where adhesions have formed it will be 
absolutely necessary to adopt .surgical methods at 
the beginning. 

Eemember that the replacement and retention of 
the uterus and adnexa by surgical procedure de- 
pend upon the shortening of the natural ligamentous 
supports, and should leave the parts as nearly nor- 
mal as possible. 

Remember that adhesive bands do not make good 
supporting structures, because they are elastic, 
usually not sufficient in extent, and they form ex- 
cellent means for the looping of the intestines and 
causing obstruction of the bowel. 

Remember that, if possible, the causes must be 
removed before a radical operation is performed; 
thus, a torn cervix or tears of the perineum or pelvic 
floor must be repaired, and the uterus curetted 
should endometritis be present. The repair of lacer- 
ations and the curettement should be done before 



122 GOLDEU KULES OF GYNECOLOGY. 

the abdomen is opened, but all may be accomplished 
•with one anesthetic. 

Kemember that the operation will probably be the 
best that utilizes the proximal part of the ligaments 
for support because of its greater strength. 

Eemember that, whatever be the operation se- 
lected, it should pull the uterus forward and upward 
and hold it firmly in position, and at the same time 
be capable of allowing for the increase in size during 
pregnancy. 

PROLAPSE OF THE UTERUS. 

Eemember that ''procidentia uteri" or prolapse 
of the uterus is a condition in which the uterus is 
found below the normal level in the pelvis. It is 
frequently spoken of by the laity as ''falling of the 
womb." 

Eemember that this condition is the first step that 
occurs in retrodisplacements ; hence the same causes 
are found in both. 

Eemember that the extent of the prolapse deter- 
mines the symptoms. The clinical manifestation in- 
cludes the following symptoms: Backache, felt 
usually in the lumbosacral region and made worse 
by standing or walking, but usually relieved on lying 
down. The pain is dragging or bearing-down in 
character and may radiate down the thighs. 

Eemember that the bladder always accompanies 
the uterine descent, because of its firm attachment 
to the cervix. This makes it impossible for the blad- 



DISEASES OP THE UTERUS. 123 

der to completely empty itself, and the residual urine 
undergoes decomposition, producing cystitis. 

Remember that as the uterus descends it drags 
down the anterior rectal wall, producing a rectocele, 
and this gives rise to the rectal symptoms of difficult 
defecation, chronic constipation, and hemorrhoids. 

Remember that the patient usually says that the 
womb is low, or drops completely outside, and upon 
examination, the vaginal opening and all the uterine 
supports are greatly relaxed — the uterus can easily 
be pushed out with the examining hands. The pa- 
tient herself can force it well out by straining. 

Remember that all women regard the upright po- 
sition for examination as vulgar and extremely em- 
barrassing, and .should not be practiced, unless it is 
necessary. 

Remember that the index finger of the left hand 
should be introduced into the vagina, and the posi- 
tion of the cervix determined. If found low and 
pointing forward in the direction of the long axis 
of the vagina, it may prove to be a prolapse of the 
first degree. The tip of the left finger should now 
be placed against the cervix to steady it, and with 
the right-hand palpation of the lower abdomen the 
position of the fundus will be found to be lower in 
the pelvis than normal, and retrodisplaced. Re- 
member that in inversion of the uterus there is a 
distinct ring completely around the protruding mass 
formed by the cervix, while the opening into the cer- 
vix cannot be demonstrated. 



124 GOLDEN KULES OF GYNECOLOGY. 

Eemember that in prolapse, unless complete, the 
fundus uteri can be located by bimanual examina- 
tion and the opening of the cervical canal can be 
easily seen. 

Eemember that in cervical polypus the uterus is 
found in its normal position, and a sound may be 
passed into the uterine cavity. 

Eemember that all cases of prolapse should be 
examined bimanually, because the uterus may be 
forced out of the pelvis by a tumor or by ascites. 

Treatment. — Eemember the first .step in the treat- 
ment is a reduction of the prolapse: the uterus 
should be grasped between the thumb and fingers, 
and steady pressure is made in the axis of the vagi- 
nal canal. When the uterus returns to the normal 
position, the patient should then be placed in the 
knee-chest posture, a Sims ' speculum introduced, and 
the vagina packed with a wool tampon saturated 
with boroglycerid. This is allowed to remain in 
place for forty-eight hours, and the patient should 
remain in bed three or four days in order that the 
congestion and edema of the uterus may be relieved. 

When the edema is pronounced it may be impos- 
sible to return the uterus. The foot of the bed 
should be elevated, and glycerin and ice-water com- 
presses applied to the uterus; should this fail, then 
multiple incisions of the cervix should be made. 

Eemember that the application of vaselin to the 
vaginal walls before attempting replacement of the 
uterus by taxis is of advantage. 



DISEASES OF THE UTERUS. 125 

Eemember that after the reduction of the pro- 
lapse the sub.sequent treatment may be either radical 
or the nse of mechanical support. Of the latter, the 
best is probably a moderate-sized globe pessary, or 
a Goddard pessary. 

Eemember that a pessary should be removed at 
night during the recumbent posture; should be thor- 
oughly washed with soap and water and dried before 
replacing; and a vaginal douche of hot normal salt 
solution should be taken. 

The pessary should be thoroughly smeared with 
an ointment of zinc oxid before replacing to pre- 
vent excoriation. 

Eemember that the following considerations 
should govern the choice of operation in attempting 
a radical cure : 

1. A prolapse in a multiparous woman cannot be 
cured by a plastic operation alone, but uterine sus- 
pension in addition is necessary. 

2. A woman of child-bearing period living with 
her husband should not be .subjected to an operation 
that produces extreme narrowing of the vagina, and 
the uterine suspension should be added to the plastic 
operations. 

3. In a woman past the menopause exaggerated 
narrowing of the vagina may suffice, provided that 
the prolapse is not too great. 

Eemember that there are two classes of operation: 
those that preserve all the genital function, and those 
that do not. 



126 GOLDEN EULES OF GYNECOLOGY. 

Under the first class there are two methods tend- 
ing to correct the pathological condition: 

1. The fastening of the fundus uteri forward and 
upward by one of the various methods of shorten- 
ing the round ligaments, and the integrity of the 
pelvic floor restored by surgical procedure. 

2. Raising the uterus high and suturing the fundus 
directly into the abdominal wall, with restoration 
of pelvic floor. 

Under the second group come the hysterectomy 
and the high fixation of the cervical stump. 

INVERSION OF THE UTERUS. 

Remember that the uterus may be partially or 
completely turned inside out. 

Remember that the cervix is dilated by the in- 
version and forms a callus around the inverted body, 
and by the contraction of the circular muscular 
fibers interferes with the replacement of the inverted 
body. 

Remember that the condition occurs in labor dur- 
ing or after the third stage, or is caused by the 
weight of a polypoid tumor growing from the fun- 
dus. 

Remember that traction on the cord in attempt- 
ing to bring away the placenta during labor is very 
likely to result in inversion. 

Remember that the symptoms depend upon the 
rapidity of the inversion, and those cases occurring 
during labor usually occur rapidly. The patient 



DISEASES OF THE UTEEUS. 127 

complains of severe pelvic pain, followed quickly by 
profuse hemorrhage and shock. 

Eemember that when the condition occurs in the 
non-gravid uterus the displacement develops slowly 
and has somewhat a chronic course. There will be 
hemorrhage, continuous with the daily loss of a 
small quantity of blood, and this eventually pro- 
duces marked anemia and general debility. There 
will also be leucorrhea, often purulent and offensive, 
suggesting malignancy. 

Eemember that these patients complain of drag- 
ging pain in the pelvis with pressure upon the rec- 
tum and bladder. 

Remember that a physical examination reveals a 
pear-shaped tumor, soft, and constricted above by 
a rim or callus — this is the cervix uteri. 

The surface of the tumor is vascular, and the pla- 
centa may or may not be attached. 

Remember that rectal touch, combined with pres- 
sure upon the abdominal wall above the pubis, re- 
veals the absence of the uterus. 

Treatment. — Remember that the uterus should be 
replaced at once in acute cases. The patient is 
anesthetized, placed in the dorsal position, and the 
reduction made by the hand. 

Remember that instrumental replacement is not 
indicated in acute cases. 

Remember that the technic of the procedure is as 
follows: Form a cone with the fingers of the left 
hand, introduced into the vagina and pressed against 



128 GOLDEN KULES OF GYNECOLOGY. 

the inverted fundus, while the fingers of the other 
hand make a counterpres.sure from above through 
the abdominal wall upon the cervical callus. If the 
manipulations are successful, the fundus passes 
slowly back through the cervical rim. 

After the replacement is accomplished, the left 
hand is kept in the uterine cavity until a douche of 
two gallons of hot saline solution is given to stimu- 
late contraction. 

Should rapid reduction fail, then the slow method 
of vaginal tamponing must be resorted to. The pa- 
tient must be kept in bed, and every other day the 
vagina is thoroughly packed with gauze; or a grad- 
ual reduction may be accomplished by the use of 
Braun's colpeurynter, using either air or water to 
distend the rubber bag. 

Eemember that if all efforts fail to reduce the 
uterus the posterior lip of the cervix may be split. 
This operation relieves the constriction and gives 
more space to restore the displaced organ. After re- 
placement the incision should be closed by inter- 
rupted sutures. 

When reduction by any method is impossible, am- 
putation of the uterus should be done. This is best 
accomplished as follows: 

1. Seize the inverted fundus with a pair of forceps 
and make strong traction. 

2. The cervix is now grasped by four forceps and 
pulled down into the vulvar opening. 

3. The fundus is caught by an additional pair of 



DISEASES OF THE UTEEUS. 129 

forceps and incised antero-posteriorly in tlie median 
line. The fingers should be introduced through the 
opening to determine if the cavity contains loops of 
intestines. The uterus is now divided into two lat- 
eral halves by carrying the antero-posterior incision 
down to the internal os. 

4. A Hagedorn needle, threaded with No. 3 catgut, 
is passed through the uterine tissue at the internal 
OS under each broad ligament and tube, and securely 
tied. These ligatures prevent retraction of the di- 
vided ligaments and hemorrhage. 

5. Three sutures are now passed transversely 
through the body of the uterus about a quarter of an 
inch from the internal os. 

6. The uterine halves are amputated just below 
the three transverse ligatures, and they are securely 
tied. 

FIBROMATA. 

While uterine fibroids are classified histologically, 
according to their predominant tissue, into fibroma, 
myoma, fibromyoma, and myoma fibroma, yet, from 
a clinical standpoint, this classification is quite un- 
necessary. Nothing is known of their origin, though 
they are quite common. 

Eemember that they occur most frequently during 
the child-bearing period of a woman ^s life. They 
are usually found in women who are sterile, or who 
have borne but one child. Many of these women are 
sterile by virtue of the presence of the fibroid, which 



130 GOLDEN" RULES OF GYNECOLOGY. 

not only destroys the uterus, but cripples and oc- 
cludes the Fallopian tubes as well. But it does seem 
that Nature has intended that the uterus should 
perform a given amount of work. May it not be 
possible that during this wonderful process of fecun- 
dation and gestation that a certain amount of some- 
thing (say energy) is expended, which, when Nature 
is cheated in her process, is utilized or expended in 
the formation of these new growths'? 

Eemember that the portion of the uterus above 
the internal os is the part principally concerned in 
gestation. While fibroids may be found in the cer- 
vix, yet they are more frequently found above the 
internal os. 

Keep in mind that fibroids are benign, though they 
may undergo various secondary changes. 

Eemember that they may atrophy at the meno- 
pause, or become calcified from the deposit of lime 
salts. Dilatation of the lymph-spaces and cyst 
formations may take place. 

Eemember that submucous fibroids may become 
pedunculated and form what are known as uterine 
polypi; this variety may become infected, and sup- 
puration takes place. Eemember also that malig- 
nant changes occur in the fibroid, and we have car- 
cinomatous and sarcomatous degeneration. 

Eemember that all fibroids are not large, and that 
they vary in size from a small shot to enormous tu- 
mors weighing several pounds. 



DISEASES OF THE UTERUS. 131 

Remember that they may occur singly, but that 
they are usually multiple. 

Remember that fibroids cause a general muscular 
hypertrophy of the walls of the uterus, and this in- 
creased weight causes uterine displacement. 

Remember that large abdominal fibroids may 
cause cardiac hypertrophy of the left side, and 
eventually fatty degeneration. The liver may also 
undergo fatty degeneration. 

Remember, too, that uterine fibroids may undergo 
various degenerative changes. 

Remember that hemorrhage is a very common 
symptom and should always arouse suspicion. 
Usually there is an increase in the amount and dura- 
tion of the menstrual flow. 

Remember that the character and location of the 
tumor will determine the amount and duration of the 
bleeding. A polypus generally causes constant 
bleeding, as well as an increase of the menstrual 
flow. Submucous and interstitial fibroids are 
usually accompanied by menorrhagia; the subserous 
and intraligamentous fibroids have little if any in- 
fluence upon menstruation. 

Clinically we speak of them as subserous, inter- 
stitial, submucous, and intraligamentous. Fre- 
quently we have all varieties in the same case. 

Remember that the subserous fibroids are under 
the peritoneum covering the uterus and are found 
from the size of a small shot to that of an enormous 



132 GOLDEN RULES OF GYNECOLOGY. 

growth; tliey liave various shapes and occur from, 
a single tumor to a multiplicity in numbers. The 
fundus may attain the size of a three or four 
months^ pregnant uterus, entirely free from ad- 
hesions, with the whole surface of the fundus or 
tumor perfectly smooth, and without the history, 
one might have considerable difficulty in making a 
diagnosis, which would be in favor of pregnancy. 

Eemember, however, that, as a rule, these women 
menstruate regularly, and quite profusely, although 
this is not invariably the case. They have no other 
evidences of pregnancy except the sjmimetrical en- 
largement of the uterus. If more convincing proof 
is necessary, then you will be able to ascertain from 
the history or a careful examination. A uterine 
sound may be used. 

Eemember, too, that in a case of interstitial 
fibroids of the uterus the early symptoms are rarely 
so severe that one cannot well afford to wait a few 
months if there is any question in the diagnosis. 

Eemember that there is little, if anything, to sug- 
gest the development of uterine fibroids early in 
their growth. There may be a slight hyperemia or 
congestion of the pelvic organs, enough, perhaps to 
produce increased menstrual flow (menorrhagia). 

Eemember, too, that there may or may not be 
sterility. Women, as a rule, do not call upon the 
physician for examination and advice concerning 
their pelvic organs until they are forced to do so 
for relief of their pain. 



DISEASES OF THE UTERUS. 133 

Eemember tliat there is no pain in the fibroid 
itself, hence there is no pain nntil the tnmors are 
large enough to produce pressure symptoms. 

Eemember that these pressure and irritating 
sjTuptoms are usually found in the bladder, rectum, 
intestines, and peritoneum. 

Remember that constant pressure and friction 
against a peritoneal surface produce a local peri- 
tonitis, followed by adhesions. 

Remember that the pain increases in proportion 
to the size and amount of impaction of the tumor 
within the pelvis. 

Keep in mind, if there is associated an intraliga- 
mentous fibroid, or one low down anteriorly or pos- 
teriorly, preventing the uterus from rising out of 
the pelvis into the abdominal cavity, that the tumor 
may fill the pelvis so that the tumor may be felt 
bulging into the vagina. 

Keep in mind that in such a case the bladder will 
be displaced, or squeezed against the pubis. There 
will be severe pressure against the rectum favoring 
constipation, and often making defecation difficult. 

Remember also that the Fallopian tubes may be 
displaced, and crippled, rendering the patient ster- 
ile. The ovaries are also displaced, and by continu- 
ous hyperemia and by pressure they finally become 
cystic. 

Keep in mind that there may be sufficient pres- 
sure against one or both ureters to cause obstruction, 
producing more or less marked hydronephrosis. 



134 GOLDEN RULES OF GYNECOLOGY. 

Eemember that these exaggerated cases rarely 
give any trouble, so far as making a diagnosis is 
concerned; but remember also that should there be 
only one subserous tumor that does not attain a very 
great size, say no larger than a hen^s egg, and if that 
should be located posteriorly or laterally, and if the 
patient is a fleshy woman, positive diagnosis may be 
quite difficult, sometimes impossible. 

Remember that in .such a case we shall have to 
differentiate between a displacement of the uterine 
fundus, cyst, or solid tumor of the ovary, or a broad 
ligament tumor. 

Remember that it is quite possible, in fact it is not 
uncommon, for pregnancy to coexist with uterine 
fibroma. 

Remember that we may be ignorant of the fact 
that there is a coexisting pregnancy at all and at 
the time of operation discover it. Or we may have 
positive knowledge of a coexisting pregnancy with 
rapidly developing uterine fibroid, due to the in- 
creased blood supply during the pregnant state. 

Remember that in the latter case we have a grave 
question to decide: one that deserves our most care- 
ful and honest consideration, because there are now 
two lives that are at stake, and all depends on our 
advice. 

Remember that she has sought relief for the rap- 
idly developing tumors which are now producing 
serious pressure symptoms, or reflex disturbances. 

Keep in mind that she may have been married for 



DISEASES OF THE TJTEBUS. 185 

a long time and that this is her first pregnancy, and 
that she is anxious for an heir. 

Eemember that as gestation advances the fibroids 
increase greatly in size, and after a while it becomes 
evident that delivery by the natural route is going 
to be extremely difficult and perhaps impossible. 
The pain and gastric disturbances are becoming al- 
most unbearable, and in all probability, she cannot 
tolerate her distress until full term. 

Eemember that you have here to consider the wel- 
fare of both the child and the mother, and undoubt- 
edly the mother's chances for recovery should be 
considered first. 

Eemember that, where it is possible to treat symp- 
tomatically and carry a patient like this along until 
the sixth or seventh month, or later if possible, then 
performing a quick supravaginal hysterectomy, hav- 
ing an incubator handy in which to place the child, 
the chances may be very good for both mother and 
child. 

Eemember that, even as early as the fifth month, 
a supravaginal hysterectomy has been done and the 
tumor laid aside for several minutes, after which 
the uterus was opened and a live fetus found, which 
was resuscitated, and lived for several hours, even 
without the use of the incubator. If proper ar- 
rangements had been made for an incubator, no 
doubt this child could have been saved; at least if a 
rapid Cesarian section had been performed and fol- 
lowed by a supravaginal hysterectomy. 



136 GOLDEN KULES OF GYNECOLOGY. 

Remember that one of tlie greatest reasons for 
mortality in Cesarian section is that the case has 
usually been in labor forty-eight hours or more with 
forceps applied, with considerable local damage to 
the uterus, and with an exhausted patient. This 
patient would have little show for life in any opera- 
tion. 

Remember, th-en, that there are no well-defined 
early symptoms of uterine fibroid except in the sub- 
mucous variety, where there may be a menorrhagia, 
and later a metrorrhagia. 

Keep in mind that, as these tumors develop, con- 
gestion of the pelvic organs increases. 

Remember that the menopause does not always 
bring relief from atrophy, as we would hope. 

Remember also that very frequently in these cases 
the menopause is indefinitely delayed, the flow is 
constant (metrorrhagia), and accompanied with 
much pain (dysmenorrhea). 

Remember that the patients are usually sterile, 
and if they become pregnant, they frequently abort. 

Remember that if congestion and engorgement 
continue the fibroids develop rapidly, and we must 
anticipate trouble. 

Keep in mind the close proximity of the bladder, 
urethra, ureters, pelvic vessels, and nerves, and the 
effect of direct pressure which is responsible for nu- 
merous complications. 

Keep in mind that anterior and posterior displace- 



DISEASES OF THE UTEEUS. 137 

ments of the fundus must not be mistaken for a 
fibroid in the anterior or posterior uterine wall. 

Eemember that fibroids usually occur in numbers, 
and that they are irregular in size, and usually are 
harder than the fundus of the uterus. 

Remember that, if it is necessary (in order to 
make a positive diagnosis), a uterine sound may be 
used (under perfectly aseptic precautions). 

Remember that ovarian cysts are softer, usually 
located laterally or posteriorly, and not always con- 
nected with the uterus. 

Remember that in normal pregnancy there is 
amenorrhea with other signs of pregnancy. 

Remember, also, that, if the doubt is sufficient, a 
few months of waiting will clear up the doubt. 

Remember that in ectopic gestation there is also 
a cessation of the menstruation with other signs of 
pregnancy. The tumor is located laterally, is soft, 
and slightly contractible to the touch. The fundus 
and cervix are enlarged and soft, with occasional 
sharp shooting pains ; and lastly, there will be severe 
pains, symptoms of hemorrhage, shock, and the 
throwing off of the decidua. 

Remember that where there are inflammatory de- 
posits in the pelvis our patient will have a history 
of some infection with sudden acute pain, and febrile 
symptoms. 

Remember that, in such a case, a soft and tender 
enlargement will usually be found in the pelvis, and 



138 GOLDEiq- RULES OF GYNECOLOGY. 

there will be exacerbations of acute symptoms of in- 
fection occurring at frequent intervals. 

Treatment. — Remember that, if the fibroids are 
quite small, and produce no symptoms, and espe- 
cially if near the menopause, they should be let 
alone. 

Remember that in a woman, near full-term preg- 
nancy, or perhaps during delivery, a fibroid as large 
as a walnut may be felt on the fundus of the uterus. 
This should not necessitate operative interference, 
as in all probability this tumor will disappear as the 
uterus undergoes involution. 

Do not undertake palliative treatment by local 
medication with any hope to yourself or to the pa- 
tient that you will effect a cure in fibroids that are 
producing symptoms of any character. 

Remember that, if you do, you will fail, and your 
patient as well as yourself will be greatly disap- 
pointed. 

Keep in mind that local treatment is only of bene- 
fit for cleansing purposes, and the temporary control 
of hemorrhage. 

Remember that the removal of the polypus pre- 
senting through the cervix gives temporary relief 
from pain and hemorrhage. Do not promise perma- 
nent relief from this, if the fundus is also nodular. 

Remember that curettage is not curative, and is 
sometimes followed by sloughing of the fibroid tu- 
mor, which gives us dangerous complications to deal 
with. 



DISEASES OF THE UTERUS. 139 

Eemember that myomectomy may be safely done 
where the fibroids are purely subserous, and in many 
of these, operation is not necessary, 

Eemember that where there is a mixture of tu- 
mors, which is so often the case (some deep-seated 
intramural), and when these are shelled out, it 
necessarily leaves a much-weakened wall of the 
uterus at that point which is in danger, should preg- 
nancy subsequently occur. 

Remember that there is one very important thing 
for us to consider, and which will become very plain 
to us after incising a uterus that has been removed 
for fibroids: that is, the great possibility of overlook- 
ing some of the new and smaller fibroids within the 
uterine wall, which means further trouble, and per- 
haps another operation for our patient. 

Remember, however, that the plan of treatment 
may be greatly modified by the age and wishes of 
the patient. 

Remember and always discuss with the patient, 
and her husband, the possibility and advisability of 
child-bearing, if she is in the child-bearing period 
bf life. 

Keep in mind that if the fibroids are numerous 
and large, and we have reason to believe that the 
function of the uterus is beyond hope, myomectomy 
is entirely out of the question, and hysterectomy 
should be done. 

Remember that, when it comes to a matter of hys- 
terectomv for the cure of uterine fibroids, the ab- 



140 GOLDEN RULES OF GYNECOLOGY. 

dominal route is by far the best and safest, and can 
be done in less time. The argument that the vagi- 
nal route is safer will not hold good. 

Eemember that, if the tumors are of any consid- 
erable size, the vaginal route is entirely out of the 
question. An operator of skill can do an abdom- 
inal operation in less time, complete the work to 
his entire satisfaction, with much less fear of hemor- 
rhage following, and his patient's convalescence will 
be just as short. 

If the cervix is large and hard, a complete (pan- 
hysterectomy) hysterectomy should be done. Many 
of these j)atients remain semi-invalids, after a 
supravaginal hysterectomy, owing to the fact that 
they have a large, heavy cervix remaining, which 
will not atrophy. They have a constant, copious 
leucorrhea, and often bloody discharges almost 
equal to a menstruation. 

Eemember that, whether the cervix is removed or 
not, the vagina may and should be raised, by fixing 
the stumps of the broad ligaments at this point, 
after which the whole is covered entirely by peri- 
toneum. This raises the vagina, keeping the an- 
terior and posterior walls of the vagina from sag- 
ging, and adds materially to the success of the 
operation, and to the future comfort of the patient, 
the end desired by both the patient and the surgeon. 

Eemember that delay is dangerous. Early opera- 
tion, under proper conditions, means small risk to 
the patient, while late operation means great risk. 



DISEASES OF THE UTEEUS. 



141 



CANCER OF THE UTERUS. 

Eemember that carcinoma of the body of the 
uterus is less frequent than cancer of the cervix and 
occurs later in life. 

Eemember that cancer of the body progresses 
much slower than that of the cervix; hence requires a 
longer time before the affection becomes inoperable. 

Remember that cervical lacerations lay the foun- 
dation for cervical cancer. 

Eemember that carcinoma of the cervix may be 
overlooked in its beginning, because the cervical wall 
around the external os may be only slightly thick- 
ened on the affected side. 

Remember that extreme friability and persistent 
bleeding on slight abrasion are strong diagnostic 
signs, and microscopic examination of an excised 
piece will positively identify cervical cancer. 

Remember that carcinoma of the cervix usually 
starts near the os externum, where the cylindrical 
and pavement epitheliums meet. The margin of the 
ulcer is irregular, hard, and usually raised. The 
base is irregular and bleeds easily. 

Remem.ber that age is an important factor and 
carcinoma uteri is most frequently found between 
the fortieth and fiftieth years, but recollect that 
there are rather frequent exceptions to the age rule. 

Remerober that irregularity of menstruation is 
often wrongly attributed to the menopause when it 
marks the presence of carcinoma of corpus uteri. 



142 GOLDEN EULES OP GYNECOLOGY. 

Eemember that frequently glandular hyperplastic 
endometritis, associated with free hemorrhage and a 
watery discharge following repeated curettage, 
should demand a miscroscopic examination of the 
scrapings and the uterus extirpated if it is found 
to be malignant. 

Eemember that a show of blood following coitus, 
straining at stool, walking, or any active exercise 
is usually the first evidence noticed. 

Eemember that the presence of a slight watery 
discharge, even though odorless, is very suggestive, 
but if the discharge has a foul odor, the evidence of 
cancer is very .strong. 

Eemember that the following points differentiate 
carcinoma from sloughing submucous myoma : 

1. Cancer causes cachexia, hemorrhage, and very 
foul 'discharge. 

2. The sloughing tissues are very friable. 

3. Epithelial proliferation seen by microscope. 
Eemember that in case of retained placenta there 

will be history of recent pregnancy; the scrapings 
are composed of myriads of long, slender threads; 
and the microscope shows products of conception. 

Eemember that tuberculosis of the endometrium 
presents a mucosa that at first is smooth, yellowish- 
white, and glistening, later becomes yellowish- white 
with nodules both on the surface and below the .sur- 
face of the endometrium. These nodules^ undergo 
caseous degeneration. 



DISEASES OF THE UTEKUS. 143 

Eemember tliat the tuberculin test in the cutane- 
ous reaction will greatly assist in determining the 
presence of a tubercular infection. 

Never omit the submission of scrapings from the 
mucosa or a piece excised from the cervix to a com- 
petent microscopist for examination, to furnish the 
final evidence of malignancy. 

Treatment. — Remember that treatment is radical 
when all the cancer can be removed ; hence the great 
importance of an early diagnosis. Palliative treat- 
ment is to be followed only when it is impossible to 
remove all the malignant growth. When the blad- 
der and rectum are involved, the vagina invaded, or 
when the uterus is fixed, hysterectomy is extra-dan- 
gerous and useless. 

Remember that the cancer may extend through 
the bladder, rectal, or uterine walls, and that great 
care must be used to avoid opening the bladder, 
bowel, or peritoneum. 

In inoperable cases, thorough cauterization is the 
best treatment today. 

This is accomplished with the cautery, either 
Paquelin or galvanic, or the red-hot iron. The sear- 
ing of the exposed surface must be thorough to ob- 
tain the most benefit. The cautery should be reap- 
plied with the return of pain or hemorrhage. 

Remember that the general treatment consists of 
good tonic, plenty of good food, light exercise. The 
bowels must be kept open and the kidneys active. 



144 GOLDEN RULES OP GYNECOLOGY. 

Daily cleansing douches, and an occasional applica- 
tion of astringents to the cavity, such as acetone or 
tincture of iodin. 

Eemember that hysterectomy is indicated if: 

1. The uterus is normally movable and .symmetri- 
cal. 

2. The uterus is not excessively enlarged. 

3. The iliac and lumbar lymphatic glands are not 
enlarged, and this is difficult to determine. 

4. The vaginal wall is not involved. 
Eemember that vaginal hysterectomy is not the 

best procedure, because of the operator's inability 
to remove all cancerous tissue and the statistical fact 
that practically all have a recurrence. 

Eemember that any operation that does not re- 
move the parametrium is not admissible as a cura- 
tive operation for cervical carcinoma. 

Eemember that in the inoperable cases the hem- 
orrhage and discharges must be checked and this 
is best accomplished by sharp curettage of the ul- 
cerating surface of the cancerous growth, followed 
by the application of the cautery as previously 
stated. 

SARCOMA. 

Eemember that sarcoma is usually primary, but 
rarely, it may be secondary, and then it generally 
starts in one of the ovaries and extends to the uterus 
by continuity. 

Eemember that age is not so important a factor 



DISEASES OF THE UTEKUS. 145 

as it is in cancer and the condition is fonnd in tlie 
extremes of life. 

Pregnancy, or the mechanical injuries of labor, 
has no predisposing effect, because it attacks nul- 
liparas more frequently than women who have borne 
children. 

Eemember that sarcomatous degeneration is not 
an infrequent occurrence in uterine fibroids. 

Eemember that there are several varieties of sar- 
comata and the malignancy varies with the different 
varieties; thus, the small round-celled sarcoma is 
most malignant, the large round-celled less, while 
the spindle-celled is least malignant. 

Eemember that the tendency of sarcoma is to send 
emboli by the veins to distant organs, as the lungs, 
liver, kidneys, spleen, and brain, and thus it differs 
from carcinoma, which is apt to travel by the lym- 
phatics. 

Eemember that sarcomatous degeneration of a 
myoma should be suspected: 

1. When the hemorrhage from the myoma in- 
creases or begins after cessation. . 

2. "When the tumor increases rapidly in size after 
the menopause. 

3. When the growth returns after removal. 

4. When ascites suddenly develops. 

5. When cachexia suddenly appears. 
Eemember that positive diagnosis is possible only 

by the microscopic examination of a specimen. 
Treatment. — Eemember that the treatment is the 



146 GOLDEN KULES OF GYNECOLOGY. 

same as it is for cancer, with this warning: unless 
all the disease can be removed, operation will hasten 
death because it opens the venous channels and thus 
favors metastasis. If the cancer is confined to the 
cavity of the uterus (endometrium), the prognosis 
after hysterectomy is favorable. 

INFLAMMATION OF THE UTERUS. 

Eemember that the female genital tract is patu- 
lous from the vulva to the peritoneal cavity; it will 
at once emphasize the great danger of infection any- 
where along the tract, and the importance of proper 
and even drastic measures that are necessary to 
check the progress of microbic invasion. 

Eemember that if the infection reaches the peri- 
toneum it may cripple the woman for life, if it spares 
life at all. 

Remember that the natural .secretions of the 
vagina are acid in reaction, and possess germicidal 
properties to some degree. They are no doubt able 
to hold the fortress during time of peace, but during 
active inflammation due to microbic irritation, these 
secretions are so diluted that their germicidal action 
is greatly diminished. 

Remember that it is seldom that an infection of 
such virulence as the gonococcic stops short of com- 
plete destruction of the whole genital apparatus; 
hence inflammation anywhere along the genital tract 
(whether it is known to be dangerous in origin or 
not) must be regarded with great .suspicion. 



DISEASES OF THE UTEEUS. 147 

METRITIS. 

Study the anatomy of the uterns carefully; study 
it minutely, so that it Trill not appear as a mere hol- 
low thing with a lining called the endometrium. 

Happily for women, the once popular term en- 
dometritis is not now so much abused, and with its 
decrease in popularity, the common use of the 
curette as of some years ago is almost a rare pro- 
cedure nowadays. 

Eemember that an acute inflammation of the en- 
dometrium alone is seldom found; it no doubt occurs 
in the beginning of some mild inflammatory proc- 
esses, but it is not detected until the deeper tissues 
of the uterus are involved. 

Eemember that there are some cases of endo- 
metritis that run a . short course and recover com- 
pletely, even without treatment; however, many of 
the so-called cases of endometritis are decidedly 
cases of metritis, and sometimes perimetritis. 

Eemember that, in the cities at least, the most 
common cause of metritis is gonorrhea, next sepsis. 
There can be no doubt that, in years gone by, when 
the uterine sound was commonly used without any 
thought of asepsis and without the use of a vaginal 
speculum, infection was frequently carried into the 
uterus by the physician. It seems reasonable to sup- 
pose that the colon bacillus was a frequent intruder 
then. 

Eemember that infection in the uterine cavity rap- 



148 GOLDEN RULES OF GYNECOLOGY. 

idly extends beyond it, by way of blood-vessels, 
lymphatics, or by continuity of tissue. 

Eemember tbat occasionally cases of known gonor- 
rheal infection in women do to all appearances com- 
pletely recover, and remain well, and they later be- 
come mothers. 

It is a happy fact that puerperal sepsis is not so 
common as formerly, since all physicians have a 
proper knowledge and regard of the necessity of 
asepsis. But remember that it does occur, and some- 
times when the physician has taken every precaution 
against it. 

Eemember that the infection must gain entrance 
in .some way through the vagina, or perhaps from a 
perineal tear. 

Eemember that it does not confine itself to the 
uterine cavity or to the uterus. The recently preg- 
nant uterus takes up the infection rapidly, until the 
entire blood-stream is virtually charged. 

Eemember now that this is a general and not a 
local condition, and must be treated so. 

Eemember that the onset is usually gradual; the 
temperature in twenty-four hours after delivery may 
be 99° to 100° F., while the pulse will range from 
90 to 100. Day by day, the temperature and pulse 
show a steady increase, and the general condition 
becomes more alarming. 

Eemember that the abdominal tenderness is not 
always great; there will be more or less abdominal 
pain and rigidity with tympanitis. 



1)ISEASES OF THE UTEKUS. 149 

Eemember that the lochial discharges usually be- 
come scanty, and are sero-sanguineous or purulent 
with slight odor. 

Kemember that these patients are more or le.ss 
delirious and sometimes have a general tremor; the 
skin- becomes mottled; the tongue has a yellowish 
coat and is dry and cracked. 

Eemember that with all these general symptom.s 
of septic infection, with its original source from the 
uterus, there is often no special local evidence of this 
great storm in the uterus ; the uterus may become the 
seat of multiple abscesses, or there may be periuter- 
ine abscesses walled off by omentum and intestines. 

Treatment. — Eemember that whatever plan of 
treatment is followed it must be general as well as 
local and must be largely supportive. 

Eemember that this patient must be carried along 
until the blood has acquired sufficient antitoxic 
properties to destroy the bacteria with which it is 
loaded. 

Eemember that antistreptococcus serum is at once 
suggested, and does seem to have a beneficial in- 
fluence in some cases, while in others it has no effect 
whatsoever. 

Eemember that the infecting micro-organisms 
may be mixed, which accounts for the failure of our 
serum. The assistance of a bacteriologist should be 
sought. 

Eemember that the general treatment must be 
.symptomatic; the bowels should be moved freely 



150 GOLDEN KULES OF GYNECOLOGY. 

every day with salines or enemata; forced feeding 
with nutritious food, eggs, milk, etc. 

Eemember that when the heart begins to run rap- 
idly and shows signs of weakening there is no tonic 
that equals strychnin, given hypodermatically in 
from %o to y^o grain, every six to four hours. The 
efficacy of quinin in these cases is doubtful, except 
for its slight tonic effect. 

Remember that whiskey sometimes increases the 
delirium. Phenacetin is usually condemned in 
febrile conditions, but it often gives excellent remis- 
sions in temperature without any harm whatever. 
It .should not be given continuously, but the nurse 
can be given a certain mark in temperature, at which 
time she should give five grains of phenacetin and 
one-half grain of codein. This should not be re- 
peated then for some hours, or until the temperature 
has reached the high mark again. If pain is great, 
it may be necessary to resort to an occasional dose 
of codein or morphin. 

Eemember that sleep is quite necessary, and as 
the patients are frequently restless and nervous, it 
may be necessary to give the various hypnotics, with 
which we have had the best success. 

Remember that the temperature bath is indis- 
pensable. 

Remember that the curette or finger should be 
used early to ascertain if any remnants of membrane 
are remaining in the uterus. Do not scrape the 



DISEASES OF THE UTEEUS. 151 

uterus miless sometliing is there — it simply opens 
new avenues for absorption. 

Eemember that many of these cases die in spite 
of treatment in ten to fourteen days. Do not mis- 
take sapremia for septicemia. 

Eemember that in sapremia the onset is delayed 
several days; the patient's convalescence after con- 
finement has been practically normal, and suddenly 
there is a chill and an elevation of temperature to 
103° or 105° F. Eemember that there is not a cor- 
responding increase in the pulse rate. 

Eemember that the patient does not seem gravely 
ill nor is there delirium. Eemember that this is 
usually due to a retained blood-clot or membrane, 
which has undergone decomposition, and the dis- 
turbance is due to absorption of the products of de- 
composition. 

Eemember that a saprophytic infection may be- 
come septic, by furnishing a medium for the devel- 
opment of .septic micro-organisms. 

Eemoval of blood-clots or membranes, and wash- 
ing out the cavity are usually followed hj recovery. 
These may have to be repeated daily for two or three 
days. 

ENDOMETRITIS. 

Eemember that the starting-point of inflammatory 
affections of the uterus is, usually, the endometrium, 
and may extend, eventually, to the muscular wall or 



152 GOLDEN KULES OF GYNECOLOGY. 

to the peritoneum. Thus the uterine mucosa is the 
origin of nearly all of the inflammatory lesions of the 
pelvic organs. 

Remember that all inflammations of the endome- 
trium may be divided into the infectious and non- 
infectious. 

Remember that septic endometritis is nearly al- 
ways found following abortion and labor. It may 
follow insertion of instruments into the uterine cav- 
ity or operative procedures upon the cervix. 

Remember that in acute endometritis there is a 
leucorrhea, sometimes profuse, or it may be thin and 
serous. 

Remember that the history of a previous opera- 
tion on the uterus or instrumental treatment should 
suggest endometritis. 

Remember that sterility and abortion are very 
common in endometritis, caused by the changes pro- 
duced in the mucosa by the disease. 

Remember that the general physical condition of 
the patient varies. She may experience no ill feel- 
ing, or she may be hysterical, complain of dyspepsia, 
flatulence, and loss of appetite. 

Remember that the speculum reveals the origin 
of the leucorrhea and usually the cause of the en- 
dometritis, such as a torn cervix. 

Remember that the gonorrheal variety of endome- 
tritis is due to the presence of the gonococci in the 
endometrium. 

Remember that in the normal state the cavum 



DISEASES OF THE UTEEUS. 153 

uteri is absolutely free from pathogenic micro- 
organisms, hence infections must come from without. 
These may occur by the organisms ascending from 
the vagina, as is seen in the gonococci; or by manipu- 
lations at labor or at time of an abortion; or the most 
common method is by instruments introduced into 
the uterus. 

Eem ember that the organisms most frequently 
found are the gonococci, the streptococci, and the 
staphylococci. Infection by other organisms is not 
so common. 

Eemember that microscopic examination reveals 
the organism causing the endometritis and should 
always be done before any opinion is given by the 
physician as to whether it be a gonococcus or strep- 
tococcus infection. 

Treatment. — Eemember that the treatment of a 
simple non-infectious case should be systemic rather 
than local and cases occurring in virgins should al- 
ways be thoroughly treated systematically before re- 
sorting to local treatment. 

Eemember that the needs are: first, a thorough 
diagnosis from the standpoint of internal medicine; 
and second, the treatment of conditions which dis- 
turb the balance in the general circulation. 

Eemember that in simple endometritis rest in bed, 
a bland diet, hot sitz-baths, and hot vaginal douches 
of water, either plain or salt, are all that are re- 
quired. 

Eemember that cases due to malposition, flexures, 



154 GOLDEN" RULES OF GYNECOLOGY. 

and stenosis, or lacerations of the cervix, should re- 
ceive appropriate treatment. 

Eemember that in chronic cases constitutional 
measures are of more value than local treatment. 

Eemember that in the non-infectious variety with 
a violent onset it is better to defer local treatment, 
in the absence of positive indications to the contrary. 

Eemember that in chronic gonorrheal cases a 
curettage will be necessary and especially should 
the cervical mucosa be thoroughly removed because 
of the many glands contained. 

Eemember that in septic cases, where there are re- 
tained membranes, the uterus should be thoroughly 
curetted and washed with some hot antiseptic so- 
lution, such as liquor cresolis 2 per cent, or a solu- 
tion of bichlorid 1:4000, or wiped out with tincture 
of iodin. The douche should be given through a 
reflex irrigator unless the cervical canal be very 
patulous, to insure unimpeded outflow of solution. 

Eemember that not attempting to do too much lo- 
cally in septic cases will insure better results. A 
good intrauterine douche at the time of dilatation 
and curettement is sufficient, followed by hot vagi- 
nal douches several times daily, and hot fomenta- 
tions over the abdomen. 

The patient should receive a good tonic treatment, 
elixir of iron, quinin, and strychnin (N. F.) or pep- 
tonate of iron and manganese, quinin bisulphate gr. 
iij, t. i. d. 



DISEASES OF THE UTEEUS. 155 

The diet must be nutritions, and fever should 
be controlled by bath. Alcoholic stimulants and am- 
monia should be used freely in severe septic cases. 

Remember that Wright's vaccines should be tried 
in general sepsis. Where possible the vaccines 
should be from patient's germs — autogenous. 
- Remember that injection of polyvalent serum 
should not be neglected when a general septic con- 
dition develops. 

ENDOCERVICITIS. 

. Remember that this condition is usually sec- 
ondary but may be primary. Gonorrhea is the most 
frequent cause of the primary. The secondary form 
usually results from an extension upward from the 
vagina but may be caused by downward extension 
from the uterus. 

Remember that the cervical canal is especially ex- 
posed to various forms of infection because of the 
anatomical relation between the cervix and vagina. 
Again, the canal usually contains germs, and any 
alteration in the canal, such as traumatism or con- 
gestion, allows the bacteria to gain entrance, mul- 
tiply rapidly, and become pathogenic. 

Remember that, owing to the presence of the 
glandular crypts that afford a lodging place and pro- 
tection, it is very difficult to destroy an infection. 

Remember that the internal os uteri offers a bar- 
rier to the passage of the germs to the uterine body. 



156 GOLDEN KULES OF GYNECOLOGY. 

Eemember tliat leucorrliea is often the only com- 
plaint. The discharge is thick, clear, and tena- 
cious, like the white of an egg. 

When the infection is pyogenic, the discharge be- 
comes opaque and creamy in color. 

Eemember that vaginal examination reveals a 
patulous OS, the vaginal portion of the cervix 
swollen, and frequently a laceration, if the patient 
be a multiparous woman. 

Treatment. — Eemember that cervical injury 
should be repaired by trachelorrhaphy or by ampu- 
tation of the cervix. 

Eemember that a thorough curettement of the 
canal is strongly indicated, unless the gonococcus be 
the infecting organism. Usually the internal os 
uteri is sufficient, for a time at least, for preventing 
the involvement of the uterine cavity in gonorrheal 
endocervicitis, and care should be exercised not to 
carry the gonococci through in the treatment. 

The application to the canal of a solution of silver 
nitrate, sixty grains to the ounce, or iodin is excel- 
lent. 

In gonorrhea some variety of silver salts should 
be used — silver nitrate, protargol, 5 per cent, or ar- 
gyol, 50 per cent solutions. 

The application of phenol for one minute followed 
by alcohol gives excellent results. , 

The vagina should be douched daily with some 
antiseptic, such as liquor cresolis comp. 2 per cent. 



DISEASES OF THE UTERUS. 157 

SUBINVOLUTION OF THE UTERUS. 

Eemember that this is an arrest of a physiologic 
process of involution, following labor or abortion, 
by means of which the uterns regains its normal size 
and weight. 

Remember that involution is fatty degeneration 
and absorption of the muscular and connective tis- 
sues of the uterus. 

Eemember that infection of the uterus during 
puerperium is one of the most frequent causes and 
the heavy uterus eventually becomes displaced. 

Remember that cervical and perineal lacerations, 
however slight, always interfere with the process of 
involution. 

Remember that displacement and subinvolution 
are often due to tight abdominal binders following 
labor; lying constantly on the back; and the getting 
out of bed too early following parturition or abor- 
tion. 

Remember that the patient complains of lumbo- 
sacral pain and a bearing-down sensation or weight 
in the pelvis. 

The amount of the menstrual flow is increased be- 
cause of the congestion. There is gastrointestinal 
disturbance with the loss of appetite; headache, 
either occipital or vertical; constipation; and eventu- 
ally hysterical symptoms develop. 

Remember that physical examination reveals a 



158 GOLDEN KULES OF GYNECOLOGY. 

large Titerus, perhaps displaced, the depth of the cav- 
ity increased. The enlargement of the uterns is 
symmetrical, and there is no tenderness. 

Treatment. — Eemember that there is usually an 
endometritis, as well as the enlarged uterus, to treat, 

Eemember that when subinvolution is associated 
with either retrodisplacement or lacerated cervix or 
perineum no cure can result until the associated le- 
sions are corrected. 

Eemember that curettement, performed as under 
endometritis, is indicated. 

The reduction in the .size of the uterus is accom- 
plished by both general and local treatment. 

Local. — A gallon of hot saline solution should be 
given slowly as a douche just before going to bed. 

Following this, the vaginal fornices should be 
packed with gauze saturated with the following: 

IJ Glycerin! 3 viij 

Magnesii sulphatis 3 v 

Phenolis 3 ss 

Misce. 

Heat until all is dissolved, being- careful not to add any water. 

Ichthyol may be added to the above. This is an 
excellent depletory, and thus relieves the local con- 
gestion and hastens venous circulation. 

Once or twice a week half to an ounce of blood 
from the cervix with a sharp bistoury. All local 
treatment must be stopped during the menstruation. 

Genekal. — A nourishing and easily digested diet 
should be given. 



DISEASES OF THE UTEEUS. 159 

Plenty of pure water should be drunk daily, as 
this relieves constipation. 

Should constipation exist, the bowels must be 
opened by use of cathartics, and those producing 
watery evacuations are best. The salines are good, 
but if anemia be present, pilulae aloes et ferri (U. S. 
P.) may be given daily and salines once a week. 

Light exercise daily in the open air and sunshine, 
such as driving and walking, should be recom- 
mended. 

SUPERINVOLUTION. 

Remember that this is a rare condition, occurring 
more often, probably, after abortion than labor. 

Remember that the atrophic changes occurring in 
the uterus cause amenorrhea and sterility. 

Remember that the history of the case is impor- 
tant, as it shows the patient in good health previous 
to her last confinement and the puerperium com- 
plicated by hemorrhage, or septic infection. 

Remember that examination reveals a uterus that 
is greatly reduced in size, and indeed it may be so 
reduced that nothing remains to mark its presence 
except a small knob in the dome of the vaginal 
vault. 

Treatment. — Remember that the basic principle in 
treatment is to increase pelvic blood supply. 

This is accomplished in the following manner : 

1. Dilate and curette the uterus. 

2. Warm vaginal douche night and morning, us- 



160 GOLDEN EULES OF GYNECOLOGY. 

ing one gallon of water at temperature between 95"^ 
and 102° F. 

3. One of the following drugs should be admin- 
istered: Manganese binoxid gr. j to v thrice daily; 
apiol iTtiv to viii thrice daily; or potassium perman- 
ganate gr. ss to j thrice daily. 

4. Constipation, when it exists, is best relieved by 
aloes combined with podophyllum. 

5. Daily exercise in the open air and general mas- 
sage and electricity should be used. 

6. Sexual intercourse should be forbidden. 

LACERATIONS OF THE CERVIX. 

Eemember that lacerations are very common and 
in many instances are caused by meddlesome ob- 
stetrics. 

The tear may be, only on one side, when it is 
spoken as unilateral; or on both sides, when it is 
called bilateral; or multiple or stellate tears, when 
there are several lacerations. 

Remember that there are no symptoms pathog- 
nomonic of the condition and those present are due 
to lesions caused by the laceration. 

These patients usually complain of bearing-down 
pains in the back in the sacral region, and disturb- 
ances of menstruation. 

Eemember that examination by both sight and 
touch reveals the pathologic condition. 

Although the cervix uteri is susceptible of great 
distention, especially with the bag of water preced- 



DISEASES OF THE UTEEUS. 161 

ing the child's head, yet it is seldom that a woman 
goes through a confinement without more or less cer- 
vical laceration. 

Nature makes a great effort to heal these tears, 
and sometimes, when they have been slight, a few 
weeks will almost entirely obliterate the injury. 

Lacerations are most frequently unilateral; often 
bilateral ; and least frequently is the stellate variety. 

Primarily, a cervical tear may not cause much 
trouble, although it does prevent to some extent per- 
fect involution of the uterus. 

Eemember, however, that later we have eversion 
of the cervical mucous membrane; increased secre- 
tion from the irritated cervical glands follows; in- 
fection and inflammation are natural sequences; 
later results may bring forth scar tissue and cystic 
degeneration. 

Sometimes the chronic inflammation leads to ex- 
tensive hypertrophy of the cervix, which becomes 
heavy and drags the uterus down into the vagina. 

Remember that if you expect to wait for pa- 
thognomonic signs and symptoms of -cervical lacera- 
tion to appear you will no doubt have let the golden 
moments slip past, and you may have serious 
complications to deal with — perhaps a carcinom- 
atous cervix. 

Let it be emphasized that the symjotoms are those 
of the complications. 

Subinvolution and inflammation are responsible 
for the menstrual disturbances; displacements bring 



162 GOLDEN RULES OF GYNECOLOGY. 

on backache, feeling of fulness, dragging sensation, 
or weight in the pelvis. 

Vesicle or rectal symptoms may be caused by 
either pressure or tension on their walls. An irri- 
tating salpingitis may result in closure of the fim- 
briae, or the uterine discharge may be sufficient to 
prevent pregnancy. 

Keep in mind, then, that cervical lacerations alone 
do not as a rule cause grave symptoms, but often a 
multiplicity of symptoms arises from cervical lacera- 
tions and the common complications. 

Eemember that an obstetrician should not dis- 
charge his patient after she has been confined, until 
two or three months have elapsed; then, upon ex- 
amination, if he finds that the cervix is entirely 
healed, with perhaps only a slight depression at the 
site of the tear, he may safely discharge her, but if 
it is still unhealed, he should advise repair within a 
reasonable time. 

Do not content yourself with a speculum exami- 
nation. Sometimes the .speculum will turn out the 
anterior and posterior lips; when there is a bilateral 
laceration, this will make the cervix appear smooth 
and perfectly intact. 

Make a digital examination first, at which time 
one can examine the entire pelvis and see if there is 
any other trouble; a laceration of the cervix can be 
readily felt with the examining finger. 

Don't fail to examine with the speculum also; that 
will bring into view the character of the discharge; 



DISEASES OF THE UTEKUS. 163 

the condition of the cervical mucosa; it will show if 
there is cervical hypertrophy, ulceration or erosion, 
or cystic degeneration. 

Eemember, while examining with the speculum, 
that it is a splendid idea to catch the anterior and 
posterior lips with hooks and draw them down; 
this brings to view the extent and character of the 
laceration. 

Treatment. — Eemember always that cancer does, 
in many cases, develop at the site of laceration. 

Eemember that' the treatment is operative; but 
not every cervical laceration needs to be operated 
on. Every woman with a lacerated cervix would 
be safer, if it were repaired, and all of them bear 
watching. The following rules furnish a guide as to 
what cases to operate on: 

1. All lacerations complicated with indurations 
and hypertrophy of cervical tissues or eversion of 
the cervical muco.sa; cystic degeneration; and ero- 
sion. 

2. Laceration causing subinvolution of the uterus, 
displacement, and endometritis. 

3. Lacerations with a sensitive plug of scar tis- 
sue in the angle of the wound. 

Eemember that if there is endometritis the cav- 
ity of the uterus should be curetted before tear is 
repaired. 

The lips of cervix should be caught with two for- 
ceps after a Sims' perineal retractor has been in- 
serted into the vagina. 



164 GOLDEIT RULES OF GYNECOLOGY. 

Tlie surfaces to be denuded are marked out with 
a scalpel on tlie torn cervical margin, in .sucli man- 
ner that the incisions pass beyond the angles of 
laceration externally, and a strip of mucous mem- 
brane about one-fourth inch wide is left in the mid- 
dle of each lip for reconstruction of the cervical 
canal. The surfaces thus outlined are entirely cut 
out beyond the scar tissue. The raw surfaces are 
coapted and held by interrupted sutures, care being 
taken in inserting them not to pass through the cer- 
vical mucosa. 

Eemember that it is important that all of the scar 
tissue be removed, and especially that at the angle 
of the wound. This tissue is easily recognized by 
touch. 

Eemember that in multiple or stellate tears ampu- 
tation of the cervix may be indicated instead of an 
attempt to repair, owing to the fact that too much 
tissue would have to be sacrificed, leaving a very 
small cervix with an uncertain cervical canal. 
Again, when the cervical mucous membrane has un- 
dergone cystic degeneration, amputation may be- 
come necessary. 

Eemember that lacerations of the cervix should 
not be repaired at the time of occurrence, as the con- 
dition of the tissues following labor is such as to pre- 
clude a correct determination of the tear, and there is 
great danger of infection. 

After operation, the patient should be kept in 



DISEASES OF THE UTEEUS. 165 

bed for ten days and not allowed to go out until at 
the end of two weeks. 

Eemember tliat all lacerations of the cervix do not 
need repair (trachelorrhaphy). When the lacera- 
tion has healed nicely with a notch on one or both 
sides, which is .soft, looks pink, and feels like the 
other portions of the cervix, it cannot well be im- 
proved, hence needs no repair. This is the normal 
cervix of the multipara. 

Eemember that a woman rarely comes for advice 
or treatment for a lacerated cervix alone, but for 
leucorrhea, menstrual disturbances, or other compli- 
cations, referable to the pelvic organs. Perhaps the 
cervical laceration was primarily to blame, but now 
these complications must be treated as well to ac- 
complish the desired results. 

Keep in mind the great necessity of examining all 
the pelvic organs for diseases of the ovaries and Fal- 
lopian tubes, displacement of the uterine fundus, 
etc., because it is absolutely necessary to take care 
of these complications if they exist to obtain the de- 
sired results. 

Eemember, if there are pelvic complications, that 
they and the cervical laceration can be taken care of 
with one anesthetic. Eepair the cervix first. If 
there has been evidence of endometritis, dilatation 
of cervix with gentle and thorough curettage of the 
entire cavity of the uterus should be done, after 
which it may be advisable to wipe out the uterus 



166 GOLDEN EULES OF GYNECOLOGY. 

with equal parts of tincture of iodin and carbolic 
acid; the vagina should be protected with cotton or 
gauze, and both the cervix and vagina should be 
cleaned off immediately with alcohol on a gauze 
sponge to prevent burning with the carbolic acid. 

Now the anterior and posterior lips of the cervix 
are grasped with single tenaculum forceps and held 
by an assistant, the perineum being retracted with 
a self -retaining retractor ; the scar tissue in each lac- 
eration is now well trimmed out, extending it as 
high as necessary into each vaginal fornix. As a 
rule, both sides may be trimmed out before any su- 
tures are introduced. If there should be severe hem- 
orrhage on account of deep excision of scar tissue, 
it may be necessary to sew up that side to prevent 
too much loss of blood before proceeding to the 
other. It is absolutely necessary to have a slip of 
cervical mucous membrane on both the anterior and 
posterior lips to make the future patulous cervical 
canal. If the lacerations necessitate the excision of 
much tissue, it is a splendid rule to place a continu- 
ous buried catgut suture first, just as in sewing up 
a deep wound elsewhere, and finally bringing the 
surfaces nicely together. If not too extensive, two 
or three sutures on each side, which include all the 
tissue, are sufficient. Absorbable suture material 
should be used unless conditions may entirely con- 
traindicate their use. Silkworm gut is rather diffi- 
cult and painful to remove, especially if the peri- 
neum, too, has to be repaired. A forty-day chromic 



DISEASES OF THE UTEEUS. 167 

catgut is perfectly reliable and will last twelve to 
fifteen days in the cervix. Van Horn prepares an 
obstetrical catgut tested to last against the action of 
the lochial discharge for ten days. 

A stellate laceration should be handled just as a 
unilateral or bilateral laceration, keeping in mind, 
however, that care must be exercised not to remove 
too much cervical tissue, so that there may follow 
an acquired cervical stenosis or atresia. 

Eemember, if there has been a great deal of dam- 
age to the cervix and it is plain that much tissue has 
to be sacrificed to get rid of all the scar tissue, that 
it may be decidedly better and safer to do an ampu- 
tation of the cervix than to attempt its repair. 

HYPERTROPHY OF THE CERVIX. 

Eemember that hypertrophy may be of either that 
part of the cervix above the vaginal junction, or 
the part below. 

Eemember that this is the only form of uterine 
prolapse met in virgins or sterile women, except in 
the rare acute cases, where the prolapse may be due 
to injury or violence. 

Eemember that supravaginal hypertrophy causes 
displacement of the uterus, due to the increased 
weight on the uterine ligaments. 

Eemember that examination reveals an elongated 
cervix, perhaps protruding at the vulvovaginal ori- 
fice; the vaginal dome is not obliterated; and the fun- 



168 GOLDEN" KULES OF GYNECOLOGY. 

dus uteri is found, either in its normal position or 
occupying a higher position than is consistent with 
the degree of cervical descent. 

Eemember that this condition occurs in virgins 
and sterile women also, while prolapse of the entire 
uterus occurs only in those who have borne children. 

Eemember that there may be no evidence of trau- 
matism in the cervix or perineum and the vaginal 
dome may be normal. 

Eemember that the knee-che.st posture causes an 
apparent elongation to disappear if due to prolapse 
of the uterus, but will have no effect in cases of 
hypertrophy. 

Treatment. — Eemember that a cure can only be ef- 
fected by surgical measures. 

Eemember that if the hypertrophy is slight and 
causes no .symptoms or discomfort nothing should be 
done. 

The best treatment is high amputation of the cer- 
vix. The incision is made above the vaginocervical 
junction, through the wall of the vagina down to the 
cervical tissue. The cervix is then pulled down by 
forceps, and the cervical tissues are separated from 
the surrounding structures in front of and behind 
the finger, as far as the uterine vessels. 

The arteries should be ligated with catgut liga- 
tures, carried around then by a curved needle. The 
cervix is now divided on each side down to the ligated 
vessels. A curved Hagedorn needle is threaded with 
silkworm gut and passed through the center of the 



DISEASES OF THE UTERUS. 169 

anterior vaginal wall, tlie loose tissue, and tlie cervix 
into tlie cervical canal. A similar suture is passed 
posteriorly. The cervical lips are amputated, and 
three or four silkworm-gut sutures passed through 
the vaginal wall and cervical tissues, similar to the 
ones already introduced ; and all are tied. A strip of 
gauze is carried along the cervical canal to internal 
OS and allowed to remain for forty-eight hours, but 
is not to be replaced. 

Eemember to keep the cervical canal open, and its 
patulency should be ascertained after the suturing is 
completed. 

CERVICAL POLYPI. 

Eemember that mucous polypi are the most fre- 
quent, but occasionally fibroid polypi and papillary 
growths are found. 

Eemember that the mucous polypi are the result of 
inflammation of the intracervical mucosa. 

Eemember that there are no distinguishing clinical 
symptoms. Leucorrhea is usual h^ present, caused by 
the endocervicitis, and should the polypus become 
infected, the discharge becomes purulent and offen- 
sive. 

Eemember that uterine hemorrhage is a fairly con- 
stant symptom and usually follows exertion, such as 
straining at stool, or sexual intercourse. It may be 
slight, or it may be so profuse and persistent that the 
patient becomes pale and waxy in appearance. 

Eemember that menorrhagia or dysmenorrhea is 



170 GOLDEN" EXILES OF GYNECOLOGY. 

very common, due to irritation and consequent uter- 
ine congestion, or to the effort of the uterus to expel 
the polypus. 

Eemember that physical examination by both 
touch and sight yields the only positive information. 
It may be necessary to dilate the cervical canal, but 
usually it is soft and patulous. 

Eemember that it .should be a routine rule of 
practice to examine microscopically every polypus 
th'at is removed to determine the question of malig- 
nancy. Never fail to observe this rule, that when 
necessary the patient may have the benefit of an 
early hysterectomy. 

Treatment. — The treatment is always surgical and 
consists in the removal of the growths. 

ACQUIRED ATRESIA OF THE CERVIX. 

Eemember that atresia of the cervix prevents the 
escape of the menstrual blood and uterine secretions. 
These gradually accumulating within the uterine 
cavity produce the following conditions: 

Hematometra, when the uterus is filled with blood. 

Hydrometra, when the accumulation is mucus. 

Pyometra, when pus. 

Physometra, when there is a collection of gases. 

Eemember that after the climacteric there will be 
no retention; hence no sjmiptoms. 

Eemember the importance of the history detailing 
an operation on the cervix; vaginitis caused by diph- 
theria, scarlatina, or variola. 



DISEASES OF THE UTEKUS. 171 

Eemember that amenorrhea accompanied by a 
menstrual molimen is very significant of atresia. 

Eemember that physical examination reveals a 
round, symmetrical, elastic tumor. If there is no 
uterine hypertrophy, fluctuation may be elicited. 
The uterine sound introduced by sight through a 
vaginal speculmn determines not only the atresia but 
also its location. 

Treatment. — Eemember that the treatment con- 
sists in opening the canal and keeping it patulous. 
This is accomplished by either incising or divulsing. 

A speculum is introduced into the vagina, and the 
anterior and posterior cervical lips are seized by 
forceps and pulled down toward the vulvar orifice. 

Should the obstruction be seen at the external os, 
it is incised by a straight bistoury. 

If higher up in the canal a dilator is passed into 
the cervical canal until it meets the obstruction; the 
cervical canal is then forcibly dilated, for a short 
time, when the blades will pass farther into the canal 
upon relaxing the pressure. A new po.sition of dila- 
tors farther up, and again dilating forcibly, tears 
apart the canal farther up. This intermittent dila- 
tation is continued until the uterine cavity is 
reached. 

The uterus is then washed out thoroughly with 
some hot antiseptic solution, as 2 per cent lysol solu- 
tion. The canal is packed tightly with strips of 
gauze, which .should remain for forty-eight hours. 

Every second day the vagina should be thor- 



172 GOLDEN RULES OF GYNECOLOGY. 

oughly douched with antiseptic solution, and the 
pack in the canal changed. The patient should re- 
main in bed ten days. She should use hot vaginal 
douches daily for several weeks after being allowed 
out of bed. 

In cases of pyometra the pack should be changed 
daily, and the uterine cavity thoroughly cleansed 
with a hot lysol douche. 

Tonics containing quinin and .strychnin should be 
given when needed. 

ACQUIRED STENOSIS OF THE CERVIX. 

Eemember that this condition is often produced 
by uterine displacements and most often caused by 
anteflexion. 

Eemember that obstructive dysmenorrhea is a 
prominent symptom, produced by the interference 
with the escape of the menstrual fluid, and conse- 
quently painful uterine contractions to force out the 
fluid. 

Eemember that sterility and leucorrhea are pres- 
ent and when associated with painful menstruation 
should arouse suspicion. 

Eemember that the passage of the uterine sound 
under strict aseptic precautions will determine not 
only the stenosis but location and probable cause. 

Treatment. — Eemember that dilatation and 
curettement of the uterus cure stenosis, but they 
should be followed by dilatations every week or two 
for five or six months to prevent recurrence. 



DISEASES OF THE UKETHRA. 173 

CHORIOEPITHELIOMA. 

Remember that this is a malignant disease de- 
veloping at the site of the placenta subsequent to 
labor or during pregnancy. 

It is always hemorrhagic in nature, characterized 
by early and widespread metastasis, and usually 
ends fatally. 

Remember that uterine hemorrhage is always 
present and usually the first indication of the malig- 
nant growth. Usually follows labor at term, abor- 
tion, or after the expulsion of a hydatid mole. May 
be continuous in bleeding but small in amount; or it 
may be profuse, resembling a postpartum hemor- 
rhage, but the things that control a postpartum 
either aggravate or have no effect upon a chorioepi- 
thelioma. 

Remember that a thin, offensive, watery discharge 
makes its appearance soon after the hemorrhage. 
It is always continuous but worse between attacks of 
hemorrhage. During progress of the disease the 
leucorrhea becomes more profuse. 

Remember that pain at seat of the disease is an 
early and constant symptom. It is usually referred 
to the pelvis or lumbosacral region and described 
as cramping, growing, or sharp and lacinating. 

Remember that in physical examination the 
vagina should be thoroughly explored for .secondary 
growths. Early, these growths occur as small 
rounded masses and are more or less hard to the 



174 CtOLDEN RULES OF GYNECOLOGY. 

touch like fibroid nodules. Later, tliey break down 
and .slough, leaving scooped-out areas of necrotic 
tissue. The cervix is soft and dilated so that the 
finger may be introduced. A tumor of the consis- 
tency of a fibroid growth, sharply defined and nodu- 
lar in character, may be felt upon the uterine wall. 
Later, the growth softens and bleeds easily, and 
eventually .sloughing occurs. 

Eemember that microscopic examination of scrap- 
ings should always be made by a competent micros- 
copist. 

Eemember cancer differs in the following: 

1. No connection with pregnancy. 

2. Occurs in advanced life — at or near the meno- 
pause. 

3. Uterine colic occurs late or not at all. 

4. Uterine wall becomes hard and indurated. 

5. Duration of disease much longer — one to two 
years. 

6. Microscopic examination shows characteristic 
structures differing from those found in chorioepi- 
thelioma. 

Treatment. — Eemember complete abdominal hys- 
terectomy and removal of metastatis if possible. 

Eemember that the value of an early diagnosis lies 
in an early radical treatment if the patient is to be 
benefited. 



CHAPTEE V 
DISEASES OF THE TUBES AND OVARIES. 

SALPINGITIS. 

Remember that this very common disease is due, 
in the vast majority of cases, to extension npward of 
an endometritis. 

Remember that there is such a condition as ca- 
tarrhal salpingitis, but the symptoms are so .slight 
as not to be noticed. 

Remember that purulent salpingitis is caused by 
septic and gonorrheal endometritis. 

Remember that the gonococci most frequently are 
the cause of- pus-tubes and this fact renders gonor- 
rhea such a serious complaint in the female. 

Remember that in addition to the symptoms 
caused by the tubal lesion consideration must be 
given to those that are dependent upon the coexist- 
ing endometritis. 

Remember that pain is an important symptom and 
may result from mechanical pressure and displace- 
ment of the uterus and appendages; or it may be 
caused by tractions upon adhesions that have formed 
between the tube and adjacent structures. 

Remember that the character and severity of the 

175 



176 * GOLDEN EULES OF GYNECOLOGY. 

pains vary from a dull lieavy sensation to acute, 
agonizing paroxysm. In some cases tlie pain takes 
tlie form of colic. 

Eemember that tlie pain is usually constant but is 
influenced by position. Thus the recumbent posture 
relieves the pelvic weight and also pain; hence these 
patients, as a rule, are better on arising in the morn- 
ing. Walking, exercise, coition, constipation, and 
often urination make the pain worse. At the 
menstrual period the congestion of pelvic organs in- 
creases the pain. 

Eemember that the pain is located in one or both 
iliac regions and may extend to the lumbosacral 
region or radiate down the thighs. 

Eemember that dysmenorrhea is a .somewhat con- 
stant characteristic symptom. It usually begins a 
week prior to the flow and does not cease for several 
days after it stops. It radiates from the iliac region 
into the pelvic cavity and down the thigh. 

Eemember that sterility is the rule in these cases, 
due to the closure of the fimbriae of the tube.s or the 
thickening of the external coat of the ovary, thus 
preventing the rupturing of the Graafian follicles 
and the escape of the ovum. 

Eemember that physical examination reveals an 
enlarged tube or a tumor in the ovarian region. All 
tumefactions should be traced, by deep palpation, 
from one of the uterine cornua. 

Eemember that adhesions can be determined by 
the latitude of uterine motion. When the pelvic 



DISEASES OF THE TUBES AND OVARIES. 177 

organs are fixed and immovable it signifies that the 
adhesions are general 

Treatment. — Remember that all cases are surgical, 
but the conditions vary the surgical procedure. 

In cases where the infection and pus are confined 
to the tubes, celiotomy is indicated; the tubes re- 
moved, adhesions broken up, and the uterus taken 
care of as indicated. In cases where the tube has 
ruptured but the ab.scess has been walled off in the 
pelvis, then it is often the part of wisdom to drain 
through the vagina first; and after several days of 
rest for the patient a subsequent operation to remove 
diseased tubes and take care 'of the adhesions and 
uterus as indicated should be done. 

Don't sacrifice both ovaries in any pelvic opera- 
tion if it is possible to avoid it; the matter of hys- 
terectomy in the case of pus-tubes must be decided 
entirely upon the merits of the case: it depends 
largely upon the character of the infection. Not 
every case of pus-tubes demands the complete loss 
of the sexual apparatus of the woman. 

DISEASES OF THE OVARIES. 

Remember that in acute cases following an infec- 
tion of the uterine mucosa and reaching the ovaries 
by way of the tubes or lymphatics the ovarian symp- 
toms cannot be separated from those dependent upon 
the uterine inflammation or the local or general peri- 
tonitis which may accompany the affection. 

Remember that in acute cases, due to sudden sup- 



178 GOLDEN EULES OP GYNECOLOGY. 

pression of the menses, exanthemata, acnte rheuma- 
tism, or poisoning from arsenic or phosphorus, there 
are pain and tenderness in the iliac regions, fever, 
and a rapid pulse. 

Eemember that the pain radiates to the lumbo- 
sacral region, bladder, thighs, and occasionally to 
the breasts. 

Eemember that the parotid gland may become 
swollen. The patient lies with her knees drawn up. 

Eemember that physical examination reveals an 
enlarged and tender ovary; and the organ is usually 
found prolapsed and adherent. If an ovarian ab- 
scess has formed, it will be felt as a round or globu- 
lar mass, and in some cases fluctuation may be 
elicited. 

Eemember that the non-puerperal ovaritis and 
appendicitis must be carefully differentiated. They 
both have sudden onset, pain, and tenderness and 
fever. Vomiting with nausea is very common in 
appendicitis. Muscular rigidity of the right rectus, 
with especial tenderness over McBurney's area, is 
somewhat characteristic of appendicitis. In appen- 
dicitis the onset is more of a general abdominal pain; 
while in acute ovaritis the pain is confined to the 
lower pelvic region, and the general svstemic dis- 
turbance is not nearly so great. 

Treatment. — Eemember that puerperal cases are 
treated the .same as acute purulent salpingitis: i.e., 
the septic endometritis is treated, and the tubal and 
ovarian troubles allowed to take care of themselves. 



DISEASES OF THE TUBES AND OVAKIES. 179 

The non-puerperal cases are treated by absolute 
rest in recumbent posture, using the bedpan when 
the bowels and bladder are to be emptied. 

The vagina is douched several times daily with a 
gallon of hot normal salt solution. Hot compresses 
or an ice bag are placed over the affected organs. 

Bowels should be opened thoroughly with a sa- 
line purge and kept open daily by half -bottle of mag- 
nesium citrate. 

The diet should be liquid for two or three days, 
then semisolid until patient is out of bed. 

Morphin should be used if much pain and restless- 
ness are present. 

Fever is controlled by sponging. The attack usu- 
ally yields in twelve or fourteen days. 

CHRONIC OVARITIS. 

Eemember that the symptoms may vary when the 
ovarian trouble is associated with endometritis, sal- 
pingitis, adhesions, and pelvic tumors. 

Remember that pain is the most constant and sig- 
nificant symptom. In one or both iliac regions, it 
is usually more severe at menstruation. The pain 
radiates to back, bladder, and down the thighs. 
Like the acute condition, the pain is worse in the 
erect posture, walking, pressure of clothing at the 
waist, sexual intercourse, during defecation or uri- 
nation. 

Eemember that menstrual disturbances vary. 
There will be, most likely, monorrhagia and metror- 



180 GOLDEN KULES OP GYNECOLOGY. 

rhagia in cystic ovaries; while the cirrhotic ovary 
produces an opposite condition. 

Eemember that a large cystic ovary may be recog- 
nized on palpation as a large, oval, or globular mass 
located on either side of the uterus in the cul-de-sac 
of Douglas. 

Remember that the cirrhotic ovary is not so easily 
palpated in the fleshy patient, but can be palpated 
through the thin and relaxed abdominal wall. 

Treatment. — Remember that the treatment may 
be palliative or radical. 

Remember that the palliative treatment is not ap- 
plicable to every case. A careful study of pelvic 
conditions should be made, and if complicated with 
salpingitis or the ovaries are greatly enlarged and 
prolapsed and the adhesions present, the palliative 
treatment is only temporary in effect. Patients 
that are dependent upon their work for a living 
should be told how much or how little benefit can be 
expected from this line of treatment. They should 
not be encouraged to pursue a line of treatment 
which requires much time and money, without a rea- 
sonable hope of success. 

Remember that after the palliative treatment is 
stopped the pain and other .symptoms usually return 
— and a cure is not permanent. 

Remember that complete rest m 'bed for five or 
six weeks should be insisted upon. The vagina 
should be douched several times daily with a gal- 
lon of hot normal salt .solution. The patient should 



DISEASES OF THE TUBES AND OVAKIES. 181. 

insert a tampon saturated with glycerin on going to 
bed, and remove it the following morning. The vag- 
inal vault and cervix should be painted twice a week 
with tincture of iodin, and a tampon of ichthyol and 
glycerin introduced and allowed to remain till fol- 
lowing morning. 

A very excellent pelvic depletory and at the same 
time anesthetic to mucosa is made as follows: 

IJ Glycerin! 3 viij 

Magnesii sulphatis .3v 

Phenolis 3 ss 

Misce. 

Heat till all are dissolved, making a clear solution. Keep free 
of water. 

Ichthyol may be added if desired, or, where an 
astringent is needed, zinc sulphate may be added. 

Internally, potassium iodid may be given with 
good results. A saturated solution is ordered and 
begun with five minims thrice daily after meals. 
The dose Is increased one minim daily until fifteen 
or twenty minims are taken. Corrosive sublimate 
is given in hundredth-grain doses, or, instead, the 
chlorid of gold and sodium in gr. ^io to Ms may be 
used for its direct effect on the ovaries. 

The bromids, either sodium or potassium, should 
be given if there is restlessness. 

A good bitter tonic is frequently indicated, and 
elixir ferri quininse et strychninse phosphatum (U. 
S. P.) in teaspoonful doses thrice daily after meals 
i.s excellent. 



182 GOLDEN KULES OP GYNECOLOGY. 

The severe menstrual pains may be relieved with 
tincture of cannabis indica, antipyrin, bromid, or the 
tincture of Pulsatilla. 

Light exercise in open air may be permitted. The 
clothing should hang from the shoulders and not 
from the waist. 

Eemember that almost all cases eventually demand 
surgical intervention. The operation varies from 
partial to complete removal of the ovaries. 
. Eemember that it is best to leave as much ovarian 
tissue as possible, if only a part of one ovary. 

Remember that where there is any uterine »dis- 
placement it should be corrected at the operation. 

PROLAPSE OF THE OVARIES. 

Remember that whei^ there is a prolapse of the 
uterus it will eventually pull the ovaries down. 

Remember that prolapse of the ovaries sometimes 
occurs in persons suffering from a chronic disease in 
which there is lo.ss of weight. The displacement is 
due to the lack of pelvic fat and the relaxed condi- 
tion of the pelvic organs and their support. 

Remember that the left ovary is more often pro- 
lapsed than the right. This is due to the following 
reasons : 

1. There are no valves in the left ovarian vein, 
and it opens at right angles into the renal. 

2. The rectum lies to the left of the median line; 
hence chronic constipation will produce its mechani- 
cal effect upon the left ovary. 



DISEASES OF THE TUBES AND OVAKIES. 183 

3. There is greater hypertrophy of the left ovary 
during pregnancy, and its weight is thereby in- 
creased. 

Eemember that there are no pathognomonic symp- 
toms and they are often combined with those caused 
by chronic ovaritis or subinvolution of the uterus. 

Eemember that pain is the most prominent symp- 
tom. It is increased by exercise, upright position, 
defecation, urination, and coitus. It is felt in the 
iliac region or deeply located in the pelvis near the 
sacrum, and it may radiate to the hips, rectum, or 
down the thighs. 

Eemember that menstruation is affected and 
dysmenorrhea is very common, and ovarian pain is 
increased during periods because of the congestion. 

Eemember that physical examination furnishes 
the only conclusive evidence, when the ovary may be 
felt. It may be recognized by its shape, and its con- 
nection with the cornu uteri. 

Treatment. — Eemember that when the prolapse is 
due to subinvolution or to debilitating diseases the 
palliative form of treatment should be followed, but 
if the ovary be greatly enlarged or adherent, this 
form of treatment is contraindicated. 

Eemember that rest is very essential and during 
menstruation the patient should be confined in bed. 
Coitus should be forbidden. The vagina should be 
douched twice daily with a gallon of hot normal 
saline solution. Daily a tampon, either of glycerin 
or of phenol-magnesium-sulphate-glycerin combina- 



184 GOLDEN EULES OF GYNECOLOGY. 

tion, should be inserted until the congestion is re- 
duced, when it is used less frequently. 

The bowels should be kept open by the use of sa- 
lines. 

The patient should assume the knee-chest posi- 
tion for fifteen or twenty minutes daily, to allow the 
pelvic organs to drop back into their normal posi- 
tion. 

Eemember that radical treatment always calls for 
a conservative operation on the ovary. 

SOLID TUMORS OF THE OVARIES. 

Eemember that fibromata are very rare and do 
not attain large size and are usually unilateral. 

Remember that there are no characteristic symp- 
toms. The tumor is not painful, unless it should 
attain a large .size and become wedged in the pelvis. 

Eemember that bimanual examination reveals a 
round, pedunculated tumor that is freely movable 
and not connected with the uterus. 

Eemember that removal of fibroids is the only 
treatment and' delay is dangerous, because it is im- 
possible to exclude malignancy. 

Eemember that cancer of the ovary is usually 
found in both ovaries and usually occurs in a cystic 
or solid ovarian tumor. 

Eemember that the early symptoms will be those 
of the benign growth in the ovary, but later when 
malignancy occurs the clinical picture changes ma- 
terially. The tumor takes on a rapid growth, 



DISEASES OF THE TUBES AND OVARIES. 185 

ascites develops, chronic peritonitis occurs, with 
cachexia and gradual loss of weight. 

Eemember that physical examination will reveal 
the presence of a pelvic tumor, which may or may 
not be ovarian in shape, but which is not connected 
with the uterus. 

Treatment. — Eemember that all tumors of the 
ovaries demand immediate removal. The benign 
may take on malignancy. 

The malignant tumor should be removed at once 
together with tubes and all enlarged pelvic glands. 

OVARIAN CYSTS. 

Eemember that the symptoms develop very grad- 
ually and the tumor is quite large before the patient 
is aware of anything abnormal occurring in the 
pelvis. 

Eemember that when the cyst is large it may press 
upon the rectum and interfere with the venous blood 
flow, causing hemorrhoids; or by pressing upon the 
bladder produce irritation, which, together with the 
lessening of its holding capacity, causes frequent 
urination. 

Eemember that the proximity of the cj^st to the 
rectum, appendix, and Fallopian tubes subjects it to 
the dangers of infection and the resulting inflam- 
mation. Tapping may also lead to infection of the 
cyst. 

Eemember that rupture of an ovarian cyst may oc- 
cur, producing sudden abdominal pain, diuresis, al- 



186 GOLDEN EXILES OF GYNECOLOGY. 

teration in the shape of the tumor, and in septic 
cysts, acute peritonitis. 

Eemember that the increased weight of the 
ovary causes displacement ; hence bimanual examina- 
tion reveals the cyst low down in the pelvis, either 
in the cul-de-sac of Douglas, or, if in the broad liga- 
ments, then low down and to the side of the uterus. 

Eemember that the tumor is round or ovoid in 
shape with a smooth surface, and regular outline. 

Eemember that great care should be used in dis- 
tinguishing between pregnancy and ovarian cysts. 

Eemember that time is an important aid in differ- 
entiating pregnancy, and the signs of pregnancy 
should be given plenty of time to manifest them- 
selves before deciding the question. 

Eemember of course that fetal m.ovements and 
heart sounds can mean but one thing. 

Eemember that in ascites an area of fluctuation 
changes with position of the body and no resistance 
is offered to the palpating hand. 

Eemember that in ascites the areas of resonance 
and dulness change with the position of the patient. 

Eemember that the upper line of dulness on per- 
cussion with the patient in the upright posture will 
be concave in ascites, but convex in an ovarian cyst. 

Treatment. — Eemember that early operation for 
the removal of the cyst is the only treatment. 

Eemember that when operation would be almost 
certainly fatal, the patient may be made temporarily 
more comfortable by tapping the cyst with a trocar. 



DISEASES OF THE TUBES AND OVAEIES. 187 

ECTOPIC GESTATION. 

(Extrauterine Pregnancy.) 

Eemember that, normally, the ovum is fertilized 
by the spermatozoa .somewhere in the tube, after 
which the ovum is carried to the uterine cavity by 
the peristaltic action of the tube and by the cilia 
within the tube, where it attaches itself; and normal 
pregnancy ensues. 

Now remember that extrauterine pregnancy is 
fertilization of the ovum and continuation of gesta- 
tion outside the cavity of the uterus. 

Eemember that ectopic gestation, extrauterine 
pregnancy, and tubal pregnancy are synonymous 
terms. It is safe to say that nearly all extrauterine 
pregnancies are tubal in the beginning; the subse- 
quent history and development of the ovum may 
change their location. 

Now remember that the cause of extrauterine preg- 
nancy is something that prevents the fertilized ovum 
from passing through the Fallopian tube to the 
uterus; and this is usually found in women who at 
some time have suffered from pelvic inflammation, 
where adhesions may have produced kinks in the 
tube, where tumors may have compressed the tube, 
where displacements of the tubes have formed an 
acute angle or twist, or where there is chronic sal- 
pingitis with swollen mucosa or strictured lumen; 
there may be a diverticulum in the Fallopian tube; 



188 GOLDEN EULES OF GYNECOLOGY. 

and it is also .said to occur in cases of congenital mal- 
formation, where the tubes are long and tortuous 
with a small canal. 

Many textbooks say ''that it occurs after a long 
period of. sterility. ' ' Now these women are doubt- 
less .sterile by virtue of the fact that the pelvic or- 
gans have been crippled by disease, and it is difficult 
for pregnancy to take place at all ; and if the sperma- 
tozoa can meet the ovum at all, tubal pregnancy 
results. These women may perhaps only ovulate 
occasionally through the thick capsule covering the 
ovaries. 

Eemember that the fertilized ovum may lodge in 
any portion of the tube that furnishes sufficient re- 
sistance. It may lodge in that portion of the tube 
that passes through the cornu of the uterus; this is 
known as interstitial pregnancy. If near the distal 
end of the tube, it is called ampullar pregnancy; 
tubo-ovarian pregnancy may occur. 

Now remember that in interstitial pregnancy rup- 
ture is likely to be later than in the other forms of 
tubal pregnancy; it may take place at any time from 
one to four months. Eupture in the other portions 
of the tube usually occurs in six to eight weeks, al- 
though it may occur as early as the fourth week and 
as late as the twelfth week. 

Now keep in mind that in the beginning the tube 
becomes hypertrophied and swollen, and the vascu- 
larity of the tube and broad ligament is greatly in- 
creased. If pregnancy is near the fimbriated ex- 



DISEASES OF THE TUBES AND OVAKIES. 189 

tremity, extrusion tlirougii fimbria or tubal abortion 
will take place. 

Remember that this may only be partial and that, 
while there will be shock, yet the hemorrhage will 
not be sufficient to cause collapse and death; but 
remember also that complete abortion may occur a 
little later with greater hemorrhage. 

Remember that after tubal abortion the fetus 
usually dies, and if the mother survives, both fetus 
and membranes may be absorbed or become im- 
bedded in the organized blood-clots, which usually 
after a few weeks become infected, and the patient 
develops symptoms of sepsis. 

Remember that rupture of the tube may be par- 
tial or complete, and may be into the abdominal 
cavity or between the folds of the broad ligaments, 
and that the severity of the symptoms varies accord- 
ingly. 

Remember that with a partial rupture the fetus 
and membranes act as a valve, the hemorrhage will 
be slow, finally clotting, so that there is a tempo- 
rary control of bleeding points. 

Keep in mind that the process may be renewed 
and more serious at any time; or it may be so severe 
from the beginning that the patient's abdomen will 
be filled with blood and she will perish from loss 
of blood. 

Remember that if rupture takes place between the 
broad ligaments the hemorrhage fortunately will be 
controlled after a time 



190 GOLDEN RULES OF GYNECOLOGY. 

Now remember that, as a rule, the product or. con- 
ception perishes, but the placenta may retain a suffi- 
cient attachment, and with the membranes unrup- 
tured the fetus may develop .to full term. 

Eemember that the fetus dies at full term if left 
alone. 

Eemember that such a child is usually iinper- 
fectly developed, both mentally and physically, and 
if removed by operation while still alive, will often 
die immediately or in a very few days. 

Eemember the interesting secondary changes that 
may take place in the fetus, after its late death. It 
may become calcitied, forming a lithopedion; it may 
become mummified ; or it may be found that nothing 
remains except the skeleton. In the first two in- 
stances the fetus may become encapsulated and re- 
main for years without disturbing the patient 
greatly; in the last case it is frequently accompa- 
nied by suppuration and rupture (usually into rec- 
tum), and the skeleton is expelled piece by piece. 

Symptoms Before Rupture. — Eemember that the 
early symptoms of extrauterine pregnancy are those 
of normal pregnancy: viz., amenorrhea; morning 
nausea ; changes in the breasts, etc. ; and the patient 
believes herself normally pregnant. 

Although many will complain of pains in the ab- 
domen and in one of the inguinal regions, yet re- 
member that some go on with no special discomfort 
until at the time of rupture. 

Eemember this: that when a patient employs you 



DISEASES OP THE TUBES AND OVAKIES. 191 

for lier physician early in pregnancy, or if she con- 
sults you for any irregularity in early pregnancy, 
a careful and thorough examination be made. Ee- 
member that the uterus will be enlarged and have 
the same characteristics as in normal pregnancy. 

Don't lay too much stress on the blue discolora- 
tion of the vaginal mucous membrane ; that may not 
be noticeable until the second or third month of 
gestation. 

Eemember that the cervix will be soft, the os 
patulous, the vagina will be moist, and the pulsating 
vessels may be felt. 

Now carefully examine the tubal regions ; the tube 
may be posterior to the uterus or clinging to the 
side of the uterus. 

Eemember that the mass is usually elongated and 
rather ovoidal in shape. 

Eemember that it is usually soft and boggy to the 
feel, and rather sensitive to the touch ; the mass may 
give the sensation of contracting. 

Eemember that the greatest care must be exer- 
cised, lest the tube may be ruptured during examina- 
tion. 

Eemember that often a history of long sterility is 
present, indicating abnormality in the Fallopian 
tubes. 

Symptoms at Time of Rupture. — Now remember 
that, although tubal rupture may be preceded by a 
few days of abdominal discomfort and pain, it 
usually comes on suddenly and without warning. 



192 GOLDEN RULES OF GYNECOLOGY. 

Eemember that it does not always follow great 
strain or exertion; it often comes with the .slight 
effort of rising from bed or a chair. 

Eemember that the patient is seized by sudden, 
severe, abdominal and pelvic pains, which are 
usually followed by pallor and collapse. 

Eemember that the pain and shock may be so .se- 
vere that the patient becomes unconscious; she will 
be deathly pale, with lips blue, pupils dilated, and 
a cold perspiration covering body; very restless 
(if not unconscious), with a shallow sighing respira- 
tion and a subnormal temperature. Nausea and 
vomiting are not uncommon. 

Eemember that, while conscious, the patient will 
be aware of the gravity of her symptoms and will 
express great fear, lest she will not recover. 

Eemember that the feeling of such a patient must 
be dreadful ; .seized suddenly in the midst of health, 
with agonizing pain; ears ringing and vision im- 
paired, until objects become hazy and dance before 
her; nausea and vomiting that only tend to increase 
the gravity of the whole situation. 

Eemember that the decidua is usually thrown off 
and there is vaginal bleeding, which may be mis- 
taken for miscarriage. 

Eemember that if the rupture has been intraperi- 
toneal, bimanual examination will reveal the cul-de- 
.sac distended into the vagina; further palpation will 
no doubt reveal the enlarged tube; the indications 
of free fluid will be found in the pelvis and abdom- 



DISEASES OF THE TUBES AND OVARIES. 193 

inal cavity. Now, if the patient survives, the blood 
coagulates, and the tumor is semisolid and often 
nodular; the pelvis is often walled off from the ab- 
dominal cavity by intestinal adhesions, or the .same 
nodular masses may be felt up in the abdominal 
cavity as well. 

Now remember, if the fetus does not perish, at 
time of rupture, gestation may continue until full 
term, when pains that more or less resemble labor 
pains occur, and the fetus dies. 

Eemember, if such a pregnancy is intraperitoneal, 
that the fetus occupies a higher position than usual; 
movements are more noticeable; the fetal heart 
sound is more easily heard and may be more easily 
palpated, because the thick uterine wall does not 
intervene; the uterus will only enlarge to about the 
size of a three or four months' pregnant uterus and 
may be pushed down or to one side. 

If it is an intraligamentous pregnancy, it will be 
accompanied by discomfort and pain; the broad 
ligaments are raised; the uterus is raised and pushed 
to the opposite side; and the vagina on one side will 
be bulging. 

Diagnosis. — Remember that the history of a prob- 
able or positive pregnancy must always be consid- 
ered. Unfortunately, few women place themselves 
in the hands of a physician early enough before 
pregnancy, to detect an abnormal condition of this 
kind before the time of rupture. Keep in mind, 
however, that it is the duty of the obstetrician to 



194 GOLDEN KULES OP GYNECOLOGY. 

make a careful examination of his case as soon as 
lie is retained, to ascertain if the pregnancy is nor- 
mal, or if conditions call for frequent examinations 
in the future. 

Eemember that, if in the first month or two of 
pregnancy the patient complains of pelvic distress 
or pain, and if upon examination a small mass may 
be felt in the region of either tube or perhaps pos- 
terior to uterus, it will need special watching. If it 
increases rapidly in size, it should call for prompt 
treatment. Don't be rough during these examina- 
tions. Handle the patient gently. 

Diagnosis at Time of Rupture. — Eemember that 
the history is of great importance; the patient has 
had sudden and severe pain followed by weakness 
and shock, which often seems as though it would 
prove fatal in a short time; there will be fluid blood- 
clots and pieces of membrane expelled from the 
uterus. 

Remember that the hemorrhage is not fatal in all 
cases; the patient revives in a way, only to have a 
recurrence of the acute symptoms in a few days, 
with more hemorrhage, and membranes expelled 
from the uterus. 

Don't fail to make a thorough bimanual examina- 
tion before resorting to curettage for a suppo.sed 
miscarriage. Eemember that in this class of cases 
the pelvis and part of the abdomen will be filled with 
hard blood-clots and the patient will often present 
symptoms of peritonitis. 



DISEASES OF THE TUBES AND OVAEIES. 195 

Treatment. — Eemember that there is but one line 
of treatment and that is operative; the operation 
should be performed as early as the condition is 
recognized or strongly suspected. While waiting 
for the surgeon, don't use proctoclysis or any other 
form of normal saline therapeutics; it will tend to 
increase the hemorrhage. It is better to administer 
m.orphin to quiet the restless patient and relieve her 
pain than to resort to stimulation. Let her have 
plenty of fresh air; she will complain of being warm 
and have difficulty in breathing. 

Remember that the ideal time to operate is before 
rupture, when the tube may be removed without 
damage to the other structures. 

Arguments have been presented from time to time 
for and against operations during extreme shock 
from hemorrhage. Now, of course, if it were possi- 
ble to state that in a certain number of hours or 
days the patient before us in a condition of collapse 
would cease bleeding and recover from her extreme 
condition, it would no doubt be safer and quite 
proper to wait ; but remember that while waiting for 
the patient to grow stronger the golden moments 
may be lost and the patient gradually sinks and 
dies while we sit by, or we may wait too long, so 
that our patient is unable to stand the operation 
later, when we finally make up our minds that it is 
useless to wait longer. 

To one who has had considerable experience with 
these cases there can be no doubt that an imme- 



196 GOLDEN RULES OF GYNECOLOGY. 

diate operation is indicated in all cases; in tlie class 
where the hemorrhage has not been severe, they can 
go through the operation safely, and doubtless are 
saved from a subsequent severe hemorrhage; in the 
class where the bleeding continues and fills the whole 
abdominal cavity, they will surely die unless the 
hemorrhage is stopped. We have never had oc- 
casion to regret operation in these cases at the 
earliest possible moment. 

Eemember that one of the great elements of suc- 
cess in operating on a grave case of hemorrhage is 
to do the work rapidly, using intravenous trans- 
fusion or hypodermoclysis during the operation, and 
proctoclysis and heat applied around patient after 
she is returned to bed. 



CHAPTER VI. 
MENSTEUATION AND ITS DISORDERS. 

PUBERTY. 

Remember that puberty is that time at which a 
young girl reaches womanhood. 

Remember that puberty is reached earlier in 
warm than in cold climates. We found in our clinic 
that the average age at which a girl reaches puberty 
is thirteen. 

Remember that the changes that take place are 
gradual and that even though a girl may be able to 
conceive at puberty she is not sufficiently developed 
to bear children before the age of 18 or 20. This age 
or period is known as the period of nubility. 

Remember that as puberty approaches the gen- 
eral contour of the girl's body changes and enlarges 
and takes the form of woman. 

Remember that habits also change with the de- 
velopment of the body from the girlish to the wom- 
anlike. 

Keep in mind that this is a critical period in a 
girl's life. The mother or a close friend should fully 
acquaint the girl with the changes that are about 
to come, and with the full duties of womanhood. 

197 



198 GOLDEN KULES OF GYNECOLOGY. 

Great care should be exercised during the first few 
periods. Keeping the feet as well as the body dry 
and warm may save her from a life of suffering. 

MENSTRUATION. 

Remember that menstruation is a physiological- 
flow of a bloody discharge from the uterus, begin- 
ning with puberty and ceasing with the menopause, 
and occurs about every 28 days. 

Remember that we have a physiological amenor- 
rhea during pregnancy and during lactation. Re- 
member also that there may be exceptions; some 
women have occasional bloody discharges during 
pregnancy; and some will menstruate during lacta- 
tion. 

Remember that they have premenstrual symptoms 
(more pronounced in some than others) : slight 
swelling of the vulva; more or less engorgement of 
all the pelvic organs, which occasions a mucous dis- 
charge that often bathes the vulva; the breasts often 
become more or less tender and .swollen; and there 
is a slight swelling of the thyroid gland. 

Remember that this hyperemic condition of the 
genital organs is responsible for the feeling of ful- 
ness and slight distress. Soon the mucous flow is 
mixed with blood, and after the active period is on, 
there is usually a feeling of relief. 

Remember that mucus, epithelial cells, and blood 
compose the flow and this continues actively for 



MEITSTKUATION AND ITS DISOKDEKS. 199 

three to four days; after which it begins to subside 
and again becomes mucus. 

Eemember that there is a considerable difference 
in the duration, time, and quantity of menstruation 
in different women. Eemember that some women 
menstruate every three weeks, while some may go 
for a number of weeks. Remember that each woman 
must be governed by what seems to be normal in 
her individual. case. Remember that what is physio- 
logical in one might be pathological in the other. 

Remember that the average length of a woman's 
menstrual life is about 35 years. 

OVULATION. 

Remember that ovulation is the maturing and 
rupturing of a Graafian follicle and the throwing- 
off or escape of the ovum. 

Remember that, according to recent investiga- 
tions, there is no doubt that the impulse that con- 
trols the menstrual cycle is supplied by the ovaries. 

Remember that the corpus luteum is directly con- 
cerned in the elaboration of the internal secretion 
that is thrown into the blood-stream. 

Remember that, according to Leo Loeb (who 
.speaks of this secretion as hormone), its function is 
twofold: one is to regulate the time between ovula- 
tions;, and the other is jto prepare the endometrium 
for the reception of the fecundated ovum and to form 
the maternal placenta. 



200 GOLDEN RULES OF GYNECOLOGY. 

MENOPAUSE. 

Eemember that the menopause (change of life, 
dodging point, climacteric) is that period in a 
woman's life when menstruation and child-bearing 
cease. 

Eemember that the menopause occurs, as a rule, 
from the ages of 42 to 48, although there is a wide 
variation from this general average. It has been 
known to occur as early as in the twenties, and to 
be delayed as late as the sixtieth or seventieth 
years. 

Eemember that pelvic diseases, with congestion 
and engorgement of pelvic organs, is often responsi- 
ble for the indefinite delay of the menopause. 

Eemember that a woman with uterine prolapse 
(of the third degree), or with tubo-ovarian disease, 
will continue to menstruate indefinitely, unless the 
uterine or pelvic lesion is cured. 

Now remember that menopause is the reverse of 
puberty, with a local and general atrophy and 
shrinking. The symmetrical outlines of the figure 
are lost, due to either atrophy or obesity. The 
breasts become shapeless and flattened; the vulva 
becomes wrinkled and flat; the vagina becomes pale 
and narrow; the uterus atrophies until it is a mere 
hard remnant, and sometimes disappears altogether; 
the hair over the genitals becomes thin and turns 
gray early. 

Eemember that, as a rule, the menses do not cease 



MEl^STRUATION AND ITS DISORDERS. 201 

suddenly and permanently (the ideal way), but very 
gradually, and after a very troublesome period of 
one, two, and sometimes three years. 

Symptoms. — Eemember that one of the most 
troublesome symptoms is the so-called ' ' hot and cold 
flashes.^' Other circulatory disturbances are ful- 
ness of the head, dizziness, palpitation of the heart, 
etc. 

Eemember that the nervous manifestations are ex- 
tremely numerous and varied : extreme nervousness, 
hysteria, melancholia, and insanity. 

Eemember that profuse hemorrhage at this time, 
or the return of menstruation after it has ceased for 
several months, or discharges streaked with blood, 
should call for a thorough examination; they may be 
due to tumors, inflammatory troubles, or cancer. 

Eemember that the menopause occurs at any time 
after removal of the ovaries, or uterus, or both, for 
diseased conditions. 

Eemember that there are exceptions and that 
sometimes the woman' will continue to menstruate 
after removal of the ovaries, from an inflamed 
uterus; and we have seen hemorrhages occur at 
regular intervals where the ovaries had been re- 
moved, together with the supravaginal amputation 
of the uterus. These hemorrhages did not cease un- 
til after the large inflamed cervix had been removed. 

Treatment. — Eemember that the treatment should 
be directed toward the improvement of the general 
health of the patient as well as the cure of local 



202 GOLDEN RULES OF GYNECOLOGY. 

disorders. The nervous and mental troubles have 
to be relieved by improvement of surroundings, if 
they are not cheerful and pleasant; agreeable and 
pleasant occupation of time; careful attention to hy- 
giene; cleanliness of the body; careful attention to 
diet, kidneys, and bowels; a moderate amount of 
exercise out of doors," when the weather permits. 

Remember that local disorders must have atten- 
tion. 

PRECOCIOUS MENSTRUATION. 

Eemember that precocious menstruation means 
the flow of blood from the uterus in a girl before the 
age of puberty. 

Now remember that it is not uncommon to find 
girls whose menstrual periods begin at eleven or 
twelve years of age; these girls are precocious in 
other respects; their form and general appearance 
assume that of a matured woman very early; they 
.simply mature early, menstruate regularly, feel no 
special inconvenience or discomfort from it; matur- 
ing early, they often marry and become mothers 
early. 

While it may occur, and cases are recorded of 
periodic bloody discharges in very young girls and 
in infants, don't be too sure that the presence of a 
little blood on the napkin or underwear is a pre- 
cocious menstruation — it may come, from the vulva 
or vagina. Remember that it may be due to irrita- 



MENSTEUATIOF AND ITS DISOEDEES. 203 

tion and adhesions of the clitoris, or about the vulva 
or hymen. It may be due to itching and rubbing 
of the parts, or to masturbation. 

Treatment.^ — Remember that a thorough inspec- 
tion of the parts is necessary; look for causes of irri- 
tation and inflammation, and remove them. The 
proper treatment at this time may save this child 
from sexual excesses and perversions. 

Remember, if this child is old enough and has 
acquired precocious habits, that she will require the 
greatest care and teachings along the lines of mo- 
rality; keeping good hours, abstaining from bad com- 
panions (boys and girls), bad books, etc., will do 
much for these girls. 

DELAYED MENSTRUATION. 

Remember that, if menstruation is delayed as late 
as the fifteenth year of life, it is known as delayed, 
or retarded, menstruation. 

Remember that menstruation may be delayed this 
long in some girls, when it will begin and occur at 
regular intervals; sometimes in these delayed cases 
the pelvic organs are poorly developed, and men- 
struation that starts later than usual occurs at ir- 
regular and prolonged intervals afterward. 

Remember that, should menstruation be delayed 
and the menstrual molimen occur with a feeling of 
fulness and distress in the vagina or uterus, or both, 
with perhaps a distention of the bladder, the case 



204 GOLDEN KULES OF GYNECOLOGY. 

should be tliorouglily investigated for congenital 
malformation or occlusion of some part of the geni- 
tal tract. 

Eemember that menstruation may be delayed by 
some debilitating disease. 

Treatment. — Treat the cause. If the genital ap- 
paratus is normal and the girl is not ill as a result 
of the delayed menses, do not give emmenagogues ; 
let her alone, and the menses will appear in due 
time. 

Eemember, if .she is suffering from some general 
disease, to treat that condition; do not undertake to 
influence or produce a menstrual flow directly. 

If the canal is not patulous, it should be treated 
as the condition requires. 

AMENORRHEA. 

Amenorrhea is an absence of menstruation. Ee^ 
member that we may have a physiologic and a 
pathologic amenorrhea. 

Eemember that physiologic amenorrhea occurs in 
the human female before puberty, during pregnancy 
and lactation, and after the menopause. Eemember, 
also, that occasionally there, will be found women 
who have a slight flow during pregnancy and during 
the latter months of lactation. 

Eemember that in imperforate hymen or imperfor- 
ated cervix the menstrual molimen occurs, but there 
is no visible flow. The menstrual fluids remain in 
the uterus (hematometra), back up in the tubes 



MENSTRUATIOISr AND ITS DISOEDEES. 205 

(hematosalpinx), or fill the vagina (hematocol- 
pus). 

Now remember that as a general rule when there 
is an absence of the vagina there is a lack of de- 
velopment, or absence of the uterus and ovaries, and 
vice versa. 

Eemember that atresia of the genital tract, result- 
ing in amenorrhea, may occur from traumatism of 
the genital tract, e. g., injuries during labor, or opera- 
tions on the cervix, where no allowance is made for a 
cervical tract or canal; or from operations, such as 
removing the ovaries, or the uterus. 

Eemember that women suffering from febrile 
diseases or the chronic debilitating diseases may 
have amenorrhea. 

Remember that women suffering from nervous and 
mental diseases are very liable to amenorrhea. 

Symptoms. — Eemember that, in the cases of con- 
genital obstruction of some portion of the canal, 
there will be much pain at each menstrual period, 
owing to the distention of the vagina or uterus, or 
both, by the accumulation of menstrual fluid, caus- 
ing distention of the parts. After a few menstrua- 
tions the abdomen may be noticeably larger, and 
some of the fluid may escape into the peritoneal 
cavity through the Fallopian tubes, causing severe 
pain in the abdomen. 

Now remember that, where there are no trouble- 
some .symptoms that accompany amenorrhea and 
where an examination reveals (in a matured girl) 



206 GOLDEN EULES OF GYNECOLOGY. 

rudimentary organs, or an absence of a part or all 
of the genital organs, the prognosis for improve- 
ment of her condition is very bad. 

Much care must be exercised regarding advice 
about matrimony. It is much better not to marry at 
all than to marry and make a complete failure. 

Treatment. — Kemember that, in the cases due to 
acute or chronic systemic diseases or to nervous or 
mental disorders, these conditions must be treated, 
and the amenorrhea will take care of itself. If 
there is some acquired stenosis or atresia of any 
part of the genital canal, it must be treated en- 
tirely on the merits of the individual case. 

Eemember that the treatment must necessarily 
depend upon the cause. Eest, with proper hygienic 
surroundings, fresh air, judicious exercise, good 
nourishing food, etc., constitute about the routine 
general treatment. 

Eemember that, in young girls who are crowded 
with work in school and at the same time ' ' doing so- 
ciety, ' ' a very important part of the treatment is to 
relieve this poor girl of some of the nervous strain; 
first of the social strain; and if her condition does not 
promptly improve, she should be taken out of school. 
This girl requires rest, and in addition a good iron 
tonic, cathartics, etc., as indicated. 

Of the various drugs used in amenorrhea, may be 
named iron, strychnin, ergot, manganese, aloes, 
apiol, oxalic acid, etc. But use direct emmena- 
gogues with caution, and if the cause can be found 



MENSTEUATION AND ITS DISOEDERS. 207 

and treated, these emmenagogues in all probability 
will not be needed. 

MENORRHAGIA AND METRORRHAGIA. 

Eemember tliat, although, theoretically, menor- 
rhagia means an excessive flow at the menstrual pe- 
riod and metrorrhagia means a flow or hemorrhage 
that does not correspond to the menstrual period, 
yet a metrorrhagia, or excessive menstrual flow, is 
practically always prolonged, and sometimes rather 
irregular by ceasing slightly or almost completely 
for a few hours or a day, to begin freshly again with 
a little exertion; hence, practically speaking, it is 
often difficult to differentiate one from the other, 
and for practical purposes the term menorrhagia 
will answer very well in both cases. 

Eemember that any pathologic condition that pro- 
duces congestion of the pelvic organs will cause 
menorrhagia, viz., chronic pelvic inflammation, ma- 
lignant disease of the uterus, displacement (espe- 
cially prolapse), inversion, tumors of either uterus 
or ovaries. 

Eemember that menorrhagia may also occur in 
hemophiliacs, in scurvy, purpura, or syphilis. It 
may occur with splenic hypertrophy, diseases of the 
liver or kidneys, and sometimes in cases of mitral 
insufficiency. 

Eemember that pieces of retained membrane or 
clots after parturition or abortion may be the cause. 
We found a woman in our clinic who had worn a 



208 GOLDEN EULES OF GYNECOLOGY. 

wire spring in the uterus for over two years to pre- 
vent pregnancy and to bring on the flow. Her flow 
had been excessive and almo.st constant. When we 
saw her, the uterus and appendages were destroyed 
by abscess formation, necessitating a complete hys- 
terectomy. 

Treatment. — Eemember that there is always a 
cause, which must be sought and treated; whether 
general or local, if corrected, the menorrhagia will 
in all probability take care of itself. 

Eemember, however, that for temporary relief 
from excessive flowing rest (absolute rest) in bed is 
necessary; if the flow continues, the foot of the bed 
may be elevated ten to twelve inches; this in itself 
will check any ordinary hemorrhage. The bowels 
should be moved daily with salines; the diet should 
be liquid (soft diet). If there is evidence of pelvic 
inflammation, frequent hot-water douches should 
be given. At sleeping time a tampon of glycerin 
and ichthyol, 10 per cent, may be inserted. This can 
be removed by the patient herself or the nurse the 
following morning ; after which give a hot douche. 

Eemember that if there is evidence of retained 
membrane or clots a thorough dilatation and curet- 
tage must be done, using a general anesthetic. Ee- 
member that drugs alone are not to be depended 
upon; they will probably fail. Among valuable 
drugs that may be used in connection with general 
treatment are mineral acids, viburnum prunifolium, 
hydrastis, ergot, hamamelis, etc. 



MENSTKUATION AND ITS DISOEDEKSo 209 

DYSMENORRHEA. 

Eemember that dysmenorrhea is only a symptom 
of some lesion of the pelvic organs, manifested by 
painful menstruation. 

Eemember that the slight discomforts felt by the 
majority of women during their menstrual periods 
should not be spoken of as dysmenorrhea. 

Causes. — Remember that dysmenorrhea is found 
in young girls, with anteflexion of the uterus or an 
extremely small canal. 

Remember that pelvic inflammation with the ad- 
ditional congestion incident to menstruation will 
cause dysmenorrhea. 

Remember that retroflexion may (though not al- 
ways) cause dysmenorrhea. 

Remember that neuralgia, rheumatism, and gout 
may cause dysmenorrhea of a very troublesome 
type. 

Symptoms. — Remember that if the dysmenorrhea 
is due to sharp flexions or obstructions the pain is 
usually excruciating at first, until there is some re- 
laxation and dilatation of the canal, when the pain 
will gradually diminish. 

Now in pelvic inflammation there is usually felt 
a constant pain or ache, and with the approach of 
menstruation this is naturally increased. After the 
flow is well begun (and it is usually quite profuse), 
there will follow a feeling of relief, the flow reliev- 
ing the engorgement and congestion. 



210 GOLDEN KULES OP GYNECOLOGY. 

Eemember that in the cases due to systemic 
troubles these must be treated as indicated. 

Treatment. — Ascertain the cause and treat ac- 
cordingly. 

Eemember that it is a very common habit of many 
women with painful menstruation to numb their 
sensibilities as much as possible with drugs and 
whiskey; and frequently they acquire the morphin or 
whiskey habit in this way. There are very few cases 
of dysmenorrhea that cannot be relieved if the cause 
is found and properly treated. 

Eemember, if the uterus is anteflexed or the canal 
is small, that a thorough dilatation under an anes- 
thetic will relieve this. It may return in a few 
months, when it should be repeated. If both dila- 
tations are well done, the trouble in all probability 
will not return. 

Eemember, if there are uterine displacement, pel- 
vic tumors, etc., they must be handled as indicated. 

Eemember that it is very important that a girl 
should be educated in the proper manner of dress, 
and her clothing should always be sufficient to keep 
her dry and warm ; disregard of this rule may be the 
means of starting the young girl on a life of suffer- 
ing. 

Eemember that constipation adds to pelvic con- 
gestion. Women should be taught the great neces- 
sity of regularity in their daily stools. 

Eemember that local treatment of daily hot 
douches and tampons of some glycerin mixture two 



MENSTEUATION AND ITS DISORDEES. 211 

or three times a week helps materially if there is 
uterine or pelvic inflammation. 

Don't undertake intrauterine applications for the 
relief of this trouble; it is doubtful if any good can 
be accomplishedj and harm might be done. A fa- 
vorite plan of ours has been to institute treatment 
with hot douches and tampons, and then at the ap- 
proach of the menstrual period the patient is put in 
bed, if possible; the diet should be soft and easily 
digested. The following is a very favorite prescrip- 
tion and is given three or four times daily for two 
or three days prior to the appearance of the flow. 
At the advent of the flow, if the pain is great, it 
may be given every hour or two, until the patient 
feels relieved, when the doses may be made much 
farther apart: 

Tinctiirpe cannabis indicse 3 ij 

Fluidextracti salicis nigrse 3 ij 

Fluidextracti ergotse 3 iv 

Elixiris aromatici q. s. ad 5 iv 

Misce. 

Sig. : Teaspoonfiil in one-third cupful of hot water every one 
to five or six hours until relieved. 

If the case is severe, three to six grains of codein 
may be added. Among other drugs are aspirin, 
sodium salicylate, phenacetin, apiol, camphor, Pulsa- 
tilla, sodium and potassium bromid, viburnum 
prunifolium, etc. 

A case of dysmenorrhea of the neuralgic type will 
test one's skill to the utmost and call upon all of one's 
therapeutic acumen. We have relieved this hys- 



212 GOLDEN RULES OF GYNECOLOGY. 

terical spasm with gr. ^^o to gr. Ko of apomorphin ; 
tMs relaxes qnicklvj and does no harm. 

The unsexing of a woman must be advised with 
the greatest caution, and not until other means have 
been exhausted, and after advice with able counsel. 



CHAPTER VII. 
DISEASES OF THE URETHRA. 

URETHRITIS. 

Remember that this is not so common as it is in 
men; gonorrhea is the most frequent cause. 

Remember that trauma during childbirth or pas- 
sage of a calculus and rough instrumentation may 
cause urethritis. 

Remember that in the gonorrheal form the symp- 
toms are more severe and consist in burning during 
urination; frequent and urgent desire to urinate; 
and the presence of manifestations of gonorrhea in 
other portions of the genital tract. 

Remember that inspection shows pus in mouth of 
urethra, or it is very easily pressed out. The ure- 
thra is tender upon pressure. 

Treatment. — Remember that rest is an important 
factor in treatment. 

Diet should be restricted to articles of food that 
will render the urine bland. Avoid meats, fried and 
greasy foods, coffee or tea, spices, vinegar, etc. 

Salines should be used to flush out the bowels. 
Should the urine be strongly acid, give alkaline min- 
eral waters, and in addition administer the acetate 

213 



214 GOLDEN EULES OF GYNECOLOGY. 

or citrate of potash ; if it is alkaline, give ammonium 
benzoate, boric acid, salol, combined with the infu- 
sion of bnchu. 

The oil of sandalwood should be given as a rou- 
tine, because of its beneficial effect upon the ure- 
thral mucosa. 

In gonorrheal urethritis local treatment is im- 
perative, and the following technic should be fol- 
lowed : 

1. With the patient in the dorsal position douche 
the vagina with 3 per cent lysol solution. Another 
good method for cleansing the vagina is the follow- 
ing: Introduce bivalve speculum, make round, soft 
balls with absorbent cotton, and use a long dis- 
secting forceps. Dip the balls of cotton in hot lysol 
solution, and by means of the dissecting forceps in- 
troduce it into the vagina through the speculum, and 
mop thoroughly back behind the cervix. Kemove, 
dry with dry cotton, and again introduce ball after 
dipping in solution. This is continued until the 
vaginal mucosa has been perfectly cleansed. 

2. Cocain solution, 4 per cent, is applied to the 
urethra on an applicator wrapped with cotton, and 
allowed to remain five minutes. 

3. A reflex catheter is introduced, and the urethra 
thoroughly washed out with hot normal salt solu- 
tion. 

4. A bivalve urethral speculum is introduced as 
far as the internal meatus, and an applicator 
wrapped with cotton and saturated with a 25 per 



DISEASES OF THE UEETHRA. 215 

cent argyrol .solution, or a 1 per cent solution of 
protargol, is passed into the canal. The speculum 
is removed, and the applicator slowly withdrawn. 
This treatment should be given daily until cured. 

When the discharge changes from purulent to 
that of egg-albumin in color, it is better to discon- 
tinue the .silver solution and use one of the follow- 
ing astringents : zinc sulphate gr. j or ij to the ounce ; 
zinc acetate gr. x to the ounce; lead acetate gr. ij 
to the ounce. 

In chronic gonorrheal conditions of the urethra 
the canal is cocainized, and the entire canal painted 
with a solution of silver nitrate, gr. v to the ounce. 
This is followed by the application of weaker so- 
lutions twice a week, until discharge stops. 

Ulcers occurring along the urethra receive the fol- 
lowing treatment: 

Cocainize the urethra; introduce the urethroscope 
to the internal meatus ; wind cotton on an applicator 
and dip into a solution of silver nitrate, one dram to 
the ounce, and touch each ulcer with the solution. 
This is repeated once a week until cured. 

Where Skene's glands are chronically involved, 
the meatus is dilated, and probe inserted; each duct 
is slit open on the urethral surface. The raw sur- 
face is cauterized with 95 per cent phenol. 

STRICTURE. 

Remember that stricture of the urethra in the fe- 
male is not nearly so common as in the male. It 



216 GOLDEN KULES OF GYNECOLOGY. 

may follow acute gonorrheal inflammation, or 
chancre, or chancroid, or tumors of the tract, or 
trauma resulting from childbirth. 

Eemember always that the incontinence or reten- 
tion that is observed in the male may also be found 
in the female. 

Eemember that the most common symptom is diffi- 
cult and frequent urination. - 

The induration at the site of the stricture may be 
palpated. 

Treatment. — The treatment is dilatation, either 
forcible or gradual. 

Forcible dilatation is indicated in the majority of 
cases. It .should not be used where the cicatricial 
tissue is so dense that too much trauma will result 
from force necessary to dilate. 

Eemember that forcible dilatation must be done 
carefully and not too rapidly, .so as to avoid tearing 
the urethra. 

Eemember that a general anesthetic should be 
given and the dilatation done at one sitting. The 
patient is placed in the dorsal position, and a small 
Hegar's uterine dilator is pas.sed. The size should 
be increased until the urethra is fully dilated. 

After the operation pass a dilator every third or 
fourth day for two or three weeks. 

Gradual dilatation is done under a local anes- 
thesia, and beginning with a small-sized dilator, the 
size is increased every third day until full dilatation 
is accomplished. 



DISEASES OF THE UKETHEA. 217 

Eemember that when the fibrous tissue is dense 
and unyielding it should be cut with a urethrotome 
by the same method as in the male, but do not fail to 
follow operation with occasional dilatations. 

VESICOURETHRAL FISSURE. 

Eemember that the location of the fissure will de- 
termine many of the symptoms: thus, if the fissure 
is wholly within the urethra, then a burning .sensa- 
tion on voiding urine would be the symptom; but if 
the fissure extends back into the base of the bladder, 
then the constant irritation of the urine, hence a 
constant burning and desire to frequently urinate, 
together with severe pain produced by the muscular 
contraction at the close of urination. 

Remember that a tender spot is found by press- 
ing over the neck of the bladder through the vagina. 

The fissure is easily seen through the urethroscope. 

Treatment. — Eemember that divulsion of the ves- 
icourethral juncture should first be tried, as a major- 
ity of cases are cured by this treatment. 

The urine is rendered bland by proper medica- 
tion, and the bowels thoroughly opened before the 
operation. 

A general anesthetic is used, and the dilatation 
done by means of a pair of Hegar's uterine dilators, 
Heginning with small and increasing in .size until 
the urethra is dilated at least one-half inch. Keep 
patient in bed one week, but the operation is not 
repeated. 



218 GOLDEN RULES OP GYNECOLOGY. 

PROLAPSE. 

Eemember that slight eversion or pouting of the 
urethral mucosa is found in women who have borne 
children, and has no pathologic significance. 

Eemember that the size and extent vary from only 
one part of the urethra to others where the entire 
circumference of the canal is involved. 

Eemember that inspection reveals a dark, con- 
gested mass protruding from the external meatus, 
in the center of which can be seen the urethral oj^en- 
ing. When the eversion is limited to a part of 
the circumference of the urethra, there will be a 
small tumor apparently attached to the margin of 
the urethral opening and resembling a caruncle in 
appearance. 

Treatment. — Eemember that the first indication 
in treatment is to discover the cause, if possible, 
and remove it. 

When the condition is recent and the mucosa 
hypertrophied, overstretched, or relaxed, good re- 
sults may follow a non-operative treatment; but 
when atrophy results from chronic changes, or the 
urethra is torn from its normal attachments, there 
is nothing but an operation that will accomplish 
any good. 

Eest in bed is necessary in non-surgical treat- 
ment. In anemic women a good iron tonic is in- 
dicated. 

If the prolapse is dependent upon irritation in the 



DISEASES OF THE UEETHKA. 219 

rectum or bladder, it is often restored when the tenes- 
mus is relieved. 

The bowels should be kept loose by the use of .sa- 
lines and potassium acetate and hexamethylenamin, 
administered to render the urine bland or innocuous. 

After the swelling and edema subside, an attempt 
should be made to reduce the prolapse, and if success- 
ful, astringent injections should be used. 

A pint of solution of alum (3 iiss), or tannic acid 
(3 i to iij), should be injected daily through the re- 
turn-flow catheter. 

Once every ten days the urethral muco.sa should 
be painted with a solution of silver nitrate (gr. ij to 

SJ). 

This line of treatment should not be continued 
longer than three months, when surgical interference 
should be resorted to if no beneficial results have 
been attained. 

The best surgical procedure is obtained by re- 
moval of the prolapsed mucosa. 

The patient should be given a general anesthetic. 
The prolapsed mucosa is seized with tissue forceps 
and made taut by traction. A chromic catgut liga- 
ture is carried through the upper edge of the ex- 
ternal meatus, directly across the canal, and out 
through the lower margin of the urethral orifice. 
The prolapsed mucous membrane is cut away in 
front of the ligature with a pair of curved scis- 
sors, and the transfixion suture is caught with a pair 
of dissecting forceps and pulled part of the way out 



220 GOLDEN KULES OF GYNECOLOGY. 

of the urethral canal. The loop thus formed is cut, 
thus leaving two sutures, which are tied. This 
controls the edge of the wound at opposite points, 
and thus prevents retraction of the mucosa. 

Next, a series of interrupted catgut sutures are 
introduced about a quarter of an inch apart com- 
pletely ' around the external meatus. The continu- 
ous suture should not be used, because of the tend- 
ency to pucker the meatus and eventually cause a 
stricture. 

The wound should be douched daily with some 
hot antiseptic solution, as a 2 per cent lysol, and a 
pad and T-bandage are applied. 

The pad should be removed for urination or de- 
fecation, and the wound should be washed. Keep 
the patient in bed a week or ten days: 

URETHROCELE. 

Eemember that this is a sacculation of the middle 
third of the posterior wall of the urethra, most often 
produced by traumatism during labor. 

Remember that partial incontinence of urine in a 
woman who has borne children should arouse sus- 
picion. 

Remember that a very frequent complication of 
urethrocele is a urethritis, and this causes frequent 
and painful micturition. 

Remember that inspection reveals a bulging on 
the anterior vaginal wall, which is easily compres- 
sible. The introduction of a sound into the urethra 



DISEAES OF THE UKETHRA. 221 

with the point downward toward posterior wall of 
the canal will slip into the sac and can be felt by 
the examining finger in the vagina. 

Eemember a thick boggy tnmor that is tender on 
pres.sure is likely to be a suburethral abscess and 
not an urethrocele. 

Treatment. — When due to obstruction at the ex- 
ternal meatus, either from stricture or tumor, the 
condition should be treated on the non-operative 
plan. The first step is the cure of stricture or re- 
moval of the tumor. 

2. Cure the coexisting urethritis. 

3. Use astringent injections recommended in the 
medicinal treatment of urethral prolapse. 

4. Skene's pessary should be worn from the be- 
ginning of treatment until cured. 

Eemember that the operative procedure varies, 
depending upon the presence of urethritis. 

When urethritis complicates urethrocele, the first 
step is to make a urethrovaginal fistula in the most 
dependent part of the urethrocele. This drains the 
tumor and prevents the accumulation and decom- 
position of urine in the sac. 

2. Treat the urethritis medicinally until cured. 

3. Close the fistula, cutting away the redundant 
tissue composing the urethrocele. 

4. Introduce a Skene's pessary, and have patient 
wear it for five or six months to prevent a return of 
the condition. 

Eemember that in ca.ses not complicated by ure- 



222 GOLDEN RULES OF GYNECOLOGY. 

tliritis an opening is made between nretlira and va- 
gina at the bottom of the urethrocele and the excess 
tissue cut away at once. The wound is sutured, and 
when the patient leaves her bed, a Skene ^s pessary 
.should be worn for several months. 

CARUNCLE. 

Eemember that these tumors usually occur late in 
the child-bearing period. They are, as a rule, found 
at the margin of the external meatus, but may be 
located in other parts of the urethral canal. 

Eemember that these are the most frequent tu- 
mors of the urethra, and while they are usually sin- 
gle, they may be multiple. 

Eemember that a small, red, raspberry-like growth 
attached to the margin of the external meatus that 
is painful on touch or urination is nearly always a 
caruncle. 

Treatment. — Eemember that a general anesthesia 
is indicated. The tumor is seized with a pair of for- 
ceps, and the pedicle cut close to the urethra with a 
pair of .scissors. These growths are liable to return; 
therefore it is a good plan to cauterize the base with 
an electric cautery and allow it to heal by granula- 
tion. 



CHAPTER VIII. 
DISEASES OF THE BLADDEE. 

CYSTITIS. 

Remember that the severity of the symptoms de- 
pends upon the degree of inflammatory changes oc- 
curring. Thus, in a mild type the symptom-group 
is: frequent micturition, vesical tenesmus, pain, and 
urinary changes. 

There is usually a feeling of tenderness over the 
base of the bladder, made more acute by standing. 

Remember that in the severe type, in addition to 
the above, there will be hematuria. The urine is 
turbid, or opaque, and contains pus, mucus,- and 
epithelial cells, also many bacteria. The reaction 
may be alkaline, when there will be present triple 
phosphates, ammonium urate, and amorphous phos- 
phate. 

Remember that in the virulent type there will be 
the foregoing group of symptoms, and in addition, 
the following general symptom.s : rigors, fever, rapid 
pulse, and in some neurasthenia ; sometimes we have 
the manifestations of a profound septic infection. 

Treatment. — Remember that rest in bed is very 

223 



224 GOLDEN RULES OF GYNECOLOGY. 

important, and the more severe the attack the more 
urgent is absolute rest. 

The diet must be concentrated, nutritious, and 
bland. 

The bowels must be kept open, and daily admin- 
istration of Rochelle salts or magnesium citrate is 
excellent. 

The urine should be rendered bland. The regu- 
lation of the diet and drink is often sufficient to ac- 
complish this. When the urine is strongly acid, 
then alkaline mineral waters should be drunk, and 
in addition, potassium acetate or citrate combined 
with the infusion of buchu should be exhibited. 
The elixir buchu et potassii acetatis (N. F.), given 
in tablespoonful doses, is an excellent diuretic and 
urinary sedative. 

If the urine is alkaline, then ammonium benzoate, 
salol, or benzoic acid should be given. 

Hexamethylenamin in five-grain doses night and 
morning should be given to check bacterial growth 
and extension along the ureters to the bladder. 
After the acute symptoms subside oil of sandalwood 
should be given for its beneficial effect on the mu- 
cosa. 

Locally, the bladder should be irrigated with 
some antiseptic solution, and a solution of perman- 
ganate of potash, 1 to 4 per cent, is the best. A sat- 
urated solution of boracic acid or 1 to 2 per cent 
solution of silver nitrate, or % to 1 per cent solution 
of lysol, may also be tried. 



DISEASES OF THE BLADDEE. 225 

VESICAL CALCULUS. 

Eemember that vesical calculi are not so common 
in women as men, owing to the shortness and dilata- 
bility of the urethral canal. 

They are always primary, because a small stone 
coming from the kidney is at once passed, and thus 
does not remain to form a nucleus for future deposit 
of urinary salts. 

Remember that improper repair of vesical fistuhe 
and cystoceles is the most common cause of vesi- 
cal calculi. 

In repairing a vesical fistula, if the sutures are 
passed through the mucous membrane, the suture 
material thus forms a nucleus upon which the uri- 
nary salts are deposited. 

Eemember that the symptoms are not character- 
istic of stone. They are the signs of cystitis rather, 
caused by trauma. 

There will be frequent and painful micturition, 
tenesmus, and in severe cases, hematuria. 

Remember that the sudden stoppage of the stream 
occurs only when the stone is small and temporarily 
obstructs the vesicourethral opening. 

Remember that the habit of constantly scratching 
the parts by a young girl should arouse suspicion of 
a .stone or other foreign body, as they almost always 
feel in the vulva the pain and .soreness produced by 
a vesical stone. 

Remember that the sound should be used to ex- 



226 ■ GOLDEN" KULES OF GYNECOLOGY. 

plore the bladder, and when it comes into contact 
with the calculus, a peculiar click is heard, and a 
grating sensation is imparted to the fingers as the 
tip of the instrument scrapes over it. 

Eemember that it is not always possible to recog- 
nize a stone with a sound, because it may have be- 
come encysted or may be covered by a clot of blood, 
or again it may have become attached to the anterior 
wall of the bladder, thus eluding the instrument. 

Eemember that cystoscopic examination should be 
made not only to confirm the diagnosis but also to 
determine the condition of the mucosa of the blad- 
der, because cystitis 'is a constant symptom when 
there is a foreign body in the bladder, and since the 
cysto scope is such a substantial help from the stand- 
point of both diagnosis and treatment, it should be 
used in practically all bladder affections. 

Treatment. — Remember that, owing to the short- 
ness and dilatability of the female urethra, small 
stones may be removed safely through it, by either 
forceps or manipulation. 

The patient .should be placed in the dorsal posi- 
tion, and the bladder thoroughly washed out with a 
hot boracic acid solution. The next step is to dilate 
the urethra and inject three ounces of warm normal 
salt solution into the bladder. Locate the .stone 
either by bimanual palpation or by the cystoscopy 
The forceps are then introduced into the bladder, 
and guided by the finger in the vagina, the stone is 
grasped by the forceps and slowly withdrawn. 



DISEASES OP THE BLABDEE. 227 

In some cases, by the vaginal fingers and counter- 
pressure over the symphysis, the stone may be 
worked along into the urethral opening, whence it 
may be pushed along by the vaginal fingers through 
the external meatus. 

Eemember that litholapaxy should be attempted 
on moderate-sized stones that are soft and easily 
crushed. After thoroughly crushing the stone, the 
bladder should be thoroughly irrigated through a 
glass catheter. 

Eemember that suprapubic cystotomy is the op- 
eration indicated in girls not having reached the age 
of puberty, and in women when the stone is very 
large. 



DIAGNOSTIC INDEX. 



(For Therapeutic Index, see page 242.) 



Abdomen, physical examination 

of, 17 
Abortion as cause of superinvo- 
lution of the uterus, 159 
in endometritis, 152 
in fibromata of the uterus, 136 
tubal, 189 
Abscess formation in erysipelas 
of the vulva, 73 
suburethral, differentiated from 
urethrocele, 221 
Acquired atresia of the cervix, 
170 
amenorrhea in, 171 
hematometra in, 170 
history in, 170 
hydrometra in, 170 
physometra in, 170 
pyometra in, 170 
of the vagina, 78 
causes of, 78 
stenosis of the cervix, 172 

caused by anteflexion. 172 
dysmenorrhea in, 172 
leucorrhea in, 172 
painful menstruation in, 

172 
produced by displacement 

of uterus, 172 
sterility in, 172 
of the vagina, 78 
causes of, 78 
Adhesions of the clitoris, 60 
examination for, 61 
may cause masturbation, 61 

neurosis, 61 
symptoms of, 61 
of the folds of the nymphge, 60, 
61 



Adhesions — cont'd. 
of the labia, 62 

hindrance to coitus, 63 
to pregnancy, 63 
Amenorrhea, 204 

caused by atresia of the va- 
ginal tract, 205 
by nervous and mental dis- 
eases, 205 
during pregnancy, physiolog- 
ical, 198 
imperforate hymen in, 204 
in acquired atresia of the cer- 
vix, 171 
in ectopic gestation, 190 
in superinvolution of the uter- 
us, 159 
pain in, 205 
pathologic, 204 
physiologic, 204 
symptoms of, 205 
Ampullar pregnancy, 188 
Anteflexion of uterus as cause of 
acquired stenosis of the 
cervix, 172 
with dysmenorrhea, 209 
Appendicitis differentiated from 

ovarian cysts, 178 
Ascites differentiated from ova- 
rian cysts, 186 
in sarcoma of the uterus, 145 
Atresia of the cervix, acquired, 
170 
of the vagina, acquired, 78 
of the vaginal tract as cause 
of amenorrhea, 205 



B 



Bartholinitis, 35 
causes of, 35 



229 



230 



DIAGNOSTIC INDEX. 



Bartholinitis — cont'd. 
discharges as, 35 
filth as, 36 
gonorrhea as, 35 
inflammation and suppura- 
tion as,. 36 
differentiated from hernia, 36 

from hydrocele, 37 
edema in, 36 
symptoms of, 36 
with pruritus, 36 
Bivalve speculum in instrumental 

diagnosis, 19 
Bladder, descent of, in prolapse 
of the uterus, 122 
diseases of the, 223-227 
stone in the, 226 
vesical calculus in the, 225 
Blood examination in diagnosis, 
21 



Cachexia, cancerous, of the va- 
gina, 99 
in sarcoma of the uterus, 145 
Calculus, vesical, 225 
Cancer as cause of vulvitis, 32 
differentiated from chorioepi- 

thelioma, 174 
of the cervix, 141 
of the ovaries, 184 
of the uterus, 141 
age in, 141 

blood following coitus in, 142 
differentiated from myoma, 
142 
from retained placenta, 142 
from tuberculosis of the 
endometrium, 142 
discharge in, 142 
endometritis with, 142 
irregularity of menstruation 
in, 14i 
of the vagina, 98 
cachexia in, 99 
pain as symptom of, 99 
with hemorrhage and dis- 
charge, 99 
Carcinoma differentiated from 
elephantiasis vulvae, 45 
uteri, 141 



Caruncle of the urethra, 222 
Catarrhal salpingitis, 175 
Cervical polypi, 124, 169 
discharge in, 169 
dysmenorrhea in, 169 
endocervicitis with, 169 
examination for, 170 
fibroid, 169 
hemorrhage in, 169 
leucorrhea in, 169 
menorrhagia in, 169 
mucous, 169 
Cervix, acquired atresia of the, 
170 
stenosis of the, 172 
cancer of the, 141 
color of the, 19 
hypertrophy of the, 161, 167 
imperforate, in amenorrhea, 

204 
lacerations of the, 160 
polypi of the, 169 
Chafing of the vulva, 70 
Chancre, 56 

character of, 57 
differentiated from chancroid, 
57 
from herpes of the vulva, 66 
period of incubation of, 57 
primary, 57 
secondary lesion of, 57 
Chancroids, 52 
appearance of, 53 
differentiated from chancre, 57 
from herpes of the vulva, 65 
discharge of, 53 
pain of, 54 
primary, 52 
secondary, 53 
time of appearance of, 53 
Change of life, 200 
Chemical diagnosis, 20 
Chest, physical examination of, 

17 
Chorioepithelioma, 173 

after expulsion of hydatid 

mole, 173 
differentiated from cancer, 174 
from postpartum hemor- 
rhage, 173 
discharge in, 173 
examination for, 173 



DIAGNOSTIC INDEX. 



231 



Chorioepithelioma — cont'd. 
hemorrhage in, 173 
leucorrhea in, 173 
pain in, 173 

pregnancy as cause of, 173 
Cirrhotic ovary, 180 
Climacteric, 200 
Clitoris, adhesions of the, 60 
Coitus, blood following, as evi- 
dence of cancer of uter- 
us, 142 
frequent, as cause of vaginitis, 

91 
interfered with by adhesions of 
labia, 63 
by cysts of the vagina, 97 
by stenosis of the vagina, 78 
Colpocele of the vagina, anterior, 
81 
posterior, 81 
Condylomata as secondary le- 
sions of syphilis, 57 
Constipation, 27 

caused by cysts of the vagina, 

93 
causes of, 27 

in cystocele and rectocele, 83 
Cystic ovary, 180 
Cystitis, 223 

frequency of urination in, 223 
hematuria in, 223 
symptoms of, 223 
urine in, 223 
Cystocele, 81 

associated with prolapse of the 

uterus, 81 
constipation in, 83 
diagnosis of, 83 

differentiated from cysts of the 
vagina, 98 
from prolapse of the uterus, 

82 
from vaginal hernia, 82 
tumors, 83 
improper repair of, cause of 

vesical calculus, 225 
symptoms of, .83 
Cystoscope, use of, in vesical cal- 
culus, 226 
Cysts of the vagina, 97 

causing constipation, 97 
hemorrhoids, 97 



Cysts of the vagina — cont'd. 

differentiated from cystocele, 
98 
from rectocele, 98 
interfering with coitus, 97 
symptoms of, 97 
of the vulvovaginal ducts, 39 
character of, 39 
glands, 38 

character of, 39 
result of gonorrhea, 38 
ovarian, 185 

differentiated from uterine 
fibroids, 137 



Delayed menstruation, 203 
Dermatitis of the vulva, simple, 

70 
Diabetes as cause of eczema of 
vulva, 67 
of vulvitis, 31 
pruritus vulvae as symptom in; 
39 
Diagnosis, 15-21 
at first glance, 15 
blood examination in, 21 
chemical, 20 

exploratory incision in, 20 
general, 15 
instrumental, 18 

bivalve speculum in, 19 
perineal retractor in, 19 
use of sound in, 19 
menstruation in reference to, 

16 
microscopical, 20 
physical, 17 
of abdomen, 17 
of chest, 17 
of pelvic organs, 17 
questions to ask patient in, 16 
Differentiating appendicitis from 
non-puerperal ovaritis, 
178 
ascites from ovarian cysts, 186 
bartholinitis from hernia, 36 
cancer from chorioepithelioma, 
174 
of the uterus from myoma, 
142 



232 



DIAGNOSTIC INDEX. 



Differentiating cancer of the 
uterus — con t'd. 

from retained placenta, 

142 
from tuberculosis of the 
endometrium, 142 
carcimoma from elephantiasis 

vulvae, 45 
chancre from chancroid, 57 
from herpes of the vulva, 
65 
chancroid from chancre, 57 
from herpes of the vulva, 
65 
chorioepithelioma from cancer, 
174 
from postpartum hemor- 
rhage, 173 
cirrhotic ovary from cystic 

ovary, 180 
cystic ovary from cirrhotic 

ovary, 180 
cystocele from cysts of the 
vagina, 98 
from prolapse of the uterus, 

82 
from vaginal hernia, 82 
tumors, 83 
cysts of the vagina from cysto- 
cele, 98 
from rectocele, 98 
of the vulvovaginal glands 
from hernia, 88 
displacements of uterus from 

fibroids, 137 
ectopic gestation from fibroids 

of uterus^ 137 
eczema from herpes of the 

vulva, 65 
elephantiasis Vulvae from carci- 
noma, 45 
from syphilis, 44 
fibroids of uterus from dis- 
placement, 137 
from ectopic gestation, 137 
from ovarian cysts, 137 
from polypi, 131 
from pregnancy, 137 
from retrodisplacement, 116 
hernia from bartholinitsis, 36 
from hydrocele of the labium 
majus, 48 



Differentiating liernia — cont'd. 
of the vagina from cysts of 
the vulvovaginal glands, 
88 
from tumor of the labium, 
88 
herpes of the vulva from 
chancre, 66 
from chancroid, 65 
from eczema, 65 
hydrocele from bartholinitis, 37 
of the labium majus from 
hernia, 48 
hypertrophy of the cervix from 
prolapse of the uterus, 
168 
myoma from cancer of the 

uterus, 142 
non-puerperal ovaritis from ap- 
pendicitis, 178 
ovarian cysts from ascites, 186 
from fibroids, 137 
from pregnancy, 186 
polypi from fibroids of the 

uterus, 131 
postpartum hemorrhage from 

chorioepithelioma, 173 
pregnancy from fibroids of the 
uterus, 137 
from ovarian cysts, 186 
prolapse of the uterus from 
cystocele, 82 
from hypertrophy of the cer- 
vix, 168 
rectocele from cysts of the va- 
gina, 98 
retained placenta from tubercu- 
losis of endometrium, 
142 
retrodisplacement of the uter- 
us from fibroids, 116 
from tubo-ovarian mass, 116 
suburethral abscess from ure- 
throcele, 221 
syphilis from elephantiasis 

vulvae, 44 
tuberculosis of endometrium 
from cancer of the uter- 
us, 142 
tubo-ovarian mass from retro- 
displacement of the 
uterus, 116 



DIAGNOSTIC INDEX. 



233 



Differentiating — cont'd. 

tumor of the labium from 

hernia of the vagina, 88 

urethrocele from suburethral 

abscess, 221 
vaginal hernia from cystocele, 
82 
tumors from cystocele, 83 
Diplococci resembling gonococci, 

105 
Discharge as symptom of cancer 
of the vagina, 99 
of menstruation, 198 
in bartholinitis, 36 
in cancer of the uterus, 142 

of the vagina, 99 
in cervical polypi, 169 
in chancroids, 53 
in chorioepithelioma, 173 
in endoeervicitis, 156 
in gonorrhea, 103 
in herpes, 65 
in metritis, 149 
in vaginitis, 91 
granular, 94 
senile, 96 
in verrucre, 59 
in vulvitis, 31 
Displacement of uterus as cause 
of acquired stenosis of 
the cervix, 172 
caused by hypertrophy of the 

cervix, 167 
differentiated from fibroids, 

137 
posterior, 112 
causes of, 113 
diagnosis of, 114 
neurasthenia in, 114 
sterility in, 114 
symptoms of, 113 
Dysmenorrhea, 209 
causes of, 209 

in acquired stenosis of the cer- 
vix, 172 
in cervical polypi, 169 
in prolapse of the ovaries, 183 
in salpingitis, 176 
in uterine fibroids, 136 
neuralgic, with vaginismus, 75 
symptoms of, 209 
■yvith anteflexion of uterus^ 209 



Dysmenorrhea — cont'd. 

with pelvic inflammation, 209 
with retroflexion of the uterus, 
209 



E 



Ectopic gestation, 187 
amenorrhea in, 190 
causes of, 187 
diagnosis of, 193 

at time of rupture, 194 
differentiated from uterine 

fibroids, 137 
examination for, 194 
fetus in, 190 
calcified, 190 
mummified, 190 
skeleton, 190 
hemorrhage in, 189, 194 
lithopedion in, 190 
pain in, 190, 192 
symptoms of, at time of rup- 
ture, 191 
before rupture, 190 
Eczema of the vulva, 67 
causes of, 67 
differentiated from herpes, 

65 
with pruitus, 67 
Edema in bartholinitis, 36 
Elephantiasis vulvae, 44 

begins as acute lymphangitis, 

44 
differentiated from carci- 
noma, 45 
from syphilis, 44 
due to Filaria sanguinis 

hominis, 44 
labia majora most frequently 
involved in, 44 
Endoeervicitis, 155 
discharge in, 156 
gonorrhea as cause of, 155 
leucorrhea in, 156 
primary, 155 
secondary, 155 
with cervical polypi, 169 
Endometritis, 147, 151 
abortion in, 152 
acute, 152 

leucorrhea in, 152 



234 



DIAGNOSTIC INDEX. 



Endometritis — cont'd. 
gonococcus in, 153 
gonorrheal, 152 
infectious, 152 
non-infectious, 152 
pregnancy in, 152 
salpingitis due to extension of, 

175 
septic, as cause of vaginitis, 91 
staphylococcus in, 153 
streptococcus in, 153 
with cancer of the uterus, 142 
Endometrium, inflammation of 
the, 147 
tuberculosis of the, differenti- 
ated from cancer of the 
uterus, 142 
Erysipelas of the vulva, 72 
abscess formation in, 73 
caused by Streptococcus ery- 

sipelatis, 72 
gangrene in, 73 
symptoms of, 72 
with pruritus, 73 
Examination for cervical polypi, 
169 
for chorioepithelioma, 173 
for ectopic gestation, 194 
for prolapse of the ovaries, 183 

of the uterus, 123 
for salpingitis, 176 
of urine, 20 

in vulvitis, 31 
of young girls or unmarried 

women, 18 
reetoabdominal, 18 
Extrauterine pregnancy, 187 



Falling of the womb, 122 
Fallopian tubes, diseases of the, 

175 
Fetus in ectopic gestation, 190 
Fibroid cervical polypi, 169 
Fibroids of the uterus, 129 

differentiated from retrodis- 
placement, 116 
Fibromata of the ovaries, 184 
of the uterus, 129 
abortion in, 136 



Fibromata of the uterus — cont'd. 
as cause of uterine displace- 
ment, 131 
differentiated from displace- 
ments, 137 
from ectopic gestation, 137 
from ovarian cysts, 137 
from polypi, 131 
from pregnancy, 137 
dysmenorrhea in, 136 
hemorrhage in, 131 
hydronephrosis in, 133 
interstitial, 131, 132 
intraligamentous, 131, 133 
menorrhagia in, 131, 132, 

136 
metrorrhagia in, 136 
pain in, 133 
pregnancy with, 134 
size of, 130 

sterility in, 129, 132, 136 
submucous, 129, 131, 136 
subserous, 131, 132 
Fibromyoma of the uterus, 129 
Filaria sanguinis hominis, ele- 
phantiasis vulvae due to, 
44 
Fissure, vesicourethral, 217 
Fistula, vesicovaginal, as cause 
of eczema of vulva, 67 
of vulvitis, 32 
Follicular vulvitis, 31 



G 



Gangrene in erysipelas of the 

vulva, 73 
Glands, vulvovaginal, cysts of, 

38 
Gonoeoccic inflammation of the 

uterus, 145 
Gonococcus in endometritis, 153 
Gonorrhea, 100 
acute, 103 

as cause of bartholinitis, 36 
of cysts of vulvovaginal 

glands, 38 
of endocervicitis, 155 
of metritis, 147 
of vaginitis, 90 
character of pus in, 103 



DIAGNOSTIC INDEX. 



235 



Gonorrhea — confd. 

chronic, 103 

communication of, 102 

diagnosis of, 104 

in children, 102 

seriousness of, 101 

symptoms of, lOB 
Gonorrheal endometritis, 152 
as cause of salpingitis, 175 

urethritis, 213 

vaginitis, 91, 104 

vulvitis, 31, 32, 104 
Gout as cause of dysmenorrhea, 

209 
Granular vaginitis, 94 



H 



Hematocolpus, 205 
Hematometra, 204 

in acquired atresia of the cer- 
vix. 170 
Hematosalpinx, 205 
Hematuria in cystitis, 223 
in vesical calculus, 225 
Hemorrhage as symptom of can- 
cer of the vagina, 99 
at menopause, 201 
in cervical polypi, 169 
in chorioepithelioma, 173 
in ectopic gestation, 189, 194 
in fibromata of the uterus, 131 
in inversion of the uterus, 127 
in sarcoma of the uterus, 145 
Hemorrhoids caused by cysts of 
the vagina, 97 
by ovarian cysts, 185 
Hernia differentiated from bar- 
tholinitis, 36 
from hydrocele of the labium 
majus, 48 
inguinolabial, 50 
of the vagina, 87 

differentiated from cystocele, 

82 
from cysts of the vulvo- 
vaginal gland, 88 
from tumor of the labium, 
88 
Herpes of the vulva, 65 

differentiated from chancre, 
66 



Herpes of -the vulva — confd. 
from chancroid, 65 
from eczema, 65 
pregnancy causing, 65 
with menstruation, 65 
History and record of patient, 
importance of keeping, 
16 
Hormone, a secretion in ovula- 
tion, 199 
Hydatid mole, chorioepithelioma 
after expulsion of, 173 
Hydrocele differentiated from 
bartholinitis, 37 
of the labium majus, 48 

differentiated from hernia, 

48 
single or double, 48 
Hydrometra in acquired atresia 

of the cervix, 170 
Hydronephrosis in uterine fi.- 

broids, 133 
Hymen, imperforate, in amenor- 
rhea, 204 
Hypertrophy of the cervix, 167 
causing displacement of the 

uterus, 167 
differentiated from prolapse 
of the uterus, 168 
from lacerations, 161 



occurring 



virgins or 



sterile women, 167, 168 
supravaginal, 167 



Imperforate cervix in amenor- 
rhea, 204 
hymen in amenorrhea, 204 
Incontinence of urine in stric- 
ture of the urethra, 216 
in urethrocele, 216 
Inflammation of the endome- 
trium, 147 
of the uterus, 146 
gonococcic, 146 
pelvic, with dysmenorrhea, 209 
Inguinolabial hernia, 50 

containing intestine, 50 
omentum, 51 
the uterus, 50, 51 
Instrumental diagnosis, 18 



236 



DIAGNOSTIC INDEX. 



Interstitial fibroids of tlie uterus, 
131, 132 
pregnancy, 188 
rupture in, 188 
Intestine, inguinolabial hernia 

containing, 50 
Intraligamentous fibroids of the 
uterus, 131, 133 
pregnancy, 193 
Intraperitoneal pregnancy, 193 
Inversion of the uterus, 126 
complete, 126 
hemorrhage in, 127 
in non-gravid uterus, 127 
leucorrhea in, 127 
partial, 126 
polypoid tumor as cause of, 

126 
pregnancy as cause of, 126 
symptoms of, 126 



K 



Kraurosis vulvae, 42 

a progressive atrophy, 42 
atrophy of labia and nvmphse 

in, 43 
may cause pruritus, 43 



Labia, atrophy of the, in krau- 
rosis vulvae, 43 
majora, adhesions of the, 62 
hydrocele of the, 48 
most common situation of 

chancre, 56 
most frequently involved in 
elephantiasis vulvae, 44 
in varicose veins, 46 
Lacerations of the cervix, 160 
bilateral, 160, 161 
causes of, 160 
examination for, 162 
leading to cancer, 161 
to hypertrophy, 161 
multiple, 160 
salpingitis from, 162 
stellate, 160, 161 
symptoms of, 161 
unilateral, 160, 161 



Lead poisoning as cause of va- 
ginismus, 75 
Leucorrhea causing dermatitis of 
the vulva, 70 
in acquired stenosis of the cer- 
vix, 172 
in acute endometritis, 152 
in cervical polypi, 169 
in chorioepithelioma, 173 
in endocervicitis, 156 
in inversion of the uterus, 127 
Lithopedion, 190 
Lymphangitis, acute, elephantia- 
sis vulvae begins as, 44 



M 



Masturbation as cause of va- 
ginismus, 75 
due to adhesions of the clitoris, 
61 
to pruritus vulvae, 40 
Menopause, 200 

age occurring at, 200 
characteristics of, 200 
hemorrhage at, 201 
symptoms of, 201 
Menorrhagia, 207 
causes of, 207 
in cervical polypi, 169 
in chronic ovaritis, 179 
in uterine fibroids, 131, 132, 
136 
Menstruation, 198 
absence of, 204 
affected by prolapse of the 

ovaries, 183 
and its disorders, 197-212 
differences in, 199 
discharge during, 198 
herpes of vulva with, 65 
in reference to diagnosis, 16 
irregularity of, in cancer of the 

uterus, 141 
painful, 209 

in acquired stenosis of the 
cervix, 172 
precocious, 20^ 
retarded, 203 
symptoms of, 198 
Metritis, 147 ||^ 

discharges in, 149 



DIAGNOSTIC INDEX. 



237 



Metritis — cont'd. 

gonorrhea as cause of, 147 

sepsis as cause of, 147 

symptoms of, 148 
Metrorrhagia, 207 

in chronic ovaritis, 179 

in uterine fibroids, 136 
Microscopical diag-nosis, 20 
Mucous cervical polypi, 169 
Myoma differentiated from can- 
cer of the uterus, 142 

fibroma of the uterus, 129 

of the uterus. 129 



N 



Nervous and mental diseases 
causing amenorrhea, 205 

Neuralgia as cause of dysmenor- 
rhea, 209 

Neuralgic dysmenorrhea, with va- 
ginismus, 75 

Neurasthenia in posterior dis- 
placement of the uterus, 
114 

Neurosis may be caused by adhe- 
sions of clitoris, 61 
pruritus vulvae due to a, 40 

Nubility, period of, 197 

Nymphae, adhesions of folds of, 
60, 61 
atrophy of, in kraurosis vulvae, 
43 



Omentum, inguinolabial hernia 

containing, 51 
Ovarian cysts, 185 

causing hemorrhoids, 185 

pregnancy, 186 
differentiated from ascites, 
186 
from pregnancy, 186 
from uterine fibroids, 137 
Ovaries, cancer of the, 184 
cirrhotic, 180 
cystic, 180 

diseases of the, 175, 177 
pain in, 178 
symptoms of, 177 
fibromata of the, 184 



Ovaries — cont'd. 

prolapse of the, 182 
solid tumors of the, 184 
Ovaritis, acute, 178 
chronic, 179 

menorrhagia in, 179 
metrorrhagia in, 179 
pain in, 179 

with prolapse of the ovaries, 
183 
non-puerperal, differentiated 
from appendicitis, 178 
Ovulation, 179 



Pain in amenorrhea, 205 

in cancer of the vagina, 99 

in chancroids, 53, 54 

in chorioepithelioma, 173 

in chronic ovaritis, 179 

in cystocele, 83 

in diseases of the ovaries, 178 

in ectopic gestation, 190, 192 

in eczema, 67 

in erysipelas, 73 

in fibromata of the uterus, 133 

in herpes, 65 

in inguinolabial hernia, 50 

in inversion of the uterus, 127 

in kraurosis vulvae, 46 

in lacerations of the cervix, 160 

in metritis, 148 

in prolapse of the ovaries, 183 
of the uterus, 122 

in salpingitis, 175 

in subinvolution of the uterus, 
157 

in vaginismus, 75 

in vaginitis, 91, 92 

in varicose veins, 46 
Palpation, vaginoabdominal, 18 
Pelvic organs, physical diagnosis 

of, 17 
Perimetritis, 147 
Perineal retractor in instrumen- 
tal diagnosis, 19 
Peritonitis caused by ovarian 

cysts, 186 
Pessaries as cause of acquired 
stenosis and atresia of 
the vagina, 78 



238 



DIAGNOSTIC INDEX. 



Physical diagnosis, 17 
Physometra in acquired atresia 

of the cervix, 170 
Placenta, chorioepithelioma de- 
veloping at the site of 
the, 173 
Polypoid tumor as cause of in- 
version of uterus, 126 
Polypus, cervical, 124, 169 
uterine, 130 

differentiated from fibroids, 
131 
Posterior displacement of the 

uterus, 112 
Postpartum hemorrhage differen- 
tiated from chorioepi- 
thelioma, 173 
Precocious menstruation, 202 
Pregnancy, adhesions of labia 
hindrance to, 63 
ampullar, 188 

as cause of chorioepithelioma, 
173 
of herpes of vulva, 65 
of inversion of the uterus, 

126 
of urethrocele, 220 
of varicose veins, 46 
differentiated from ovarian 
cysts, 186 
from uterine fibroids, 137 
extrauterine, 187 
granular vaginitis in, 95 
in endometritis, 152 
interstitial, 188 
intraligamentous, 193 
intraperitoneal, 193 
normal, 187 

physiological amenorrhea dur- 
ing, 198 
tubal, 187 
tubo-ovarian, 188 
varicose veins in, 47 
with uterine fibroids, 134 
Procidentia uteri, 122 
Prolapse of the ovaries, 182 
dysmenorrhea in, 183 
examination for, 183 
menstruation affected by, 

183 
pain in, 183 
with chronic ovaritis, 183 



Prolapse of the ovaries — cont'd. 
with subinvolution of the 
uterus, 183 
of the urethra, 218 
of the uterus, 122 

differentiated from eystocele, 
82 
from hypertrophy of the 
cervix, 168 
examination for, 123- 
falling of bladder in, 122 
producing rectocele, 123 
symptoms of, 122 
with eystocele and rectocele, 
81 
Pruritus vulvae, 39 

a reflex symptom, 39 
bartholinitis with, 36 
caused by digestive disturb- 
ances, 40 
due to a neurosis, 40 
eczema with, 67 
erysipelas with, 73 
kraurosis vulvse may cause, 

42 
result of masturbation, 40 

of sexual excess, 40 
symptom in diabetes, 39 
vulvitis with, 31 
with granular vaginitis, 95 
Puberty, 197 
age of, 197 
changes in, 197 
Puerperal sepsis, 148 
Purulent salpingitis, 175 
Pus in bartholinitis, 36 

in gonorrhea, character of, 103 
in vulvitis, 31 
Pyometra in acquired atresia of 
the cervix, 170 



R 



Pectoabdominal examination, 18 
Rectocele, 81 

differentiated from cysts of the 

vagina, 98 
produced by prolapse of the 
uterus, 123 
Retained placenta differentiated 
from cancer of the uter- 
us, 142 



DEAGNOSTIC INDEX. 



239 



Retractor, perineal, in instru- 
mental diagnosis, 19 

Retrodisplacement of the uterus 
differentiated from fi- 
broids, 116 
from tubo-ovarian mass, 
116 

Retroflexion of the uterus, 115 
witli dysmenorrhea, 209 

Retroversion of the uterus, 113 

Rheumatism as cause of dys- 
menorrhea, 209 



Saccharomyces albicans as cause 

of thrush of vulva, 69. 
Salpingitis, 175 
catarrhal, 175 

due to extension of endometri- 
tis, 175 
dysmenorrhea in, 176 
examination for, 176 
from lacerations of the cervix, 

162 • 
pain in, 175 
purulent, 175 
sterility in, 176 
Sarcoma of the uterus, 144 
age in, 144 
ascites in, 145 
cachexia in, 145 
hemorrhage in, 145 
round-celled, large, 145 

small, 145 
spindle-celled, 145 
symptoms of, 145 
Senile vaginitis, 95 
Sepsis as cause of metritis, 147 

puerperal, 148 
Sexual excesses resulting in pru- 
ritus vulvae, 40 
Sound in instrumental diagnosis, 

19 
Speculum, bivalve, in instrumen- 
tal diagnosis, 19 
examination with, for lacera- 
tions of cervix, 163 
Spirochwta pallida, 58 
Staphvlococcus in bartholinitis, 
36 
in endometritis, 153 



Stenosis of the cervix, acquired, 

172 

of the vagina, acquired, 78 

Sterility in acquired stenosis of 

the cervix, 172 

in fibromata of the uterus, 129, 

132, 136 
in retrodisplacement of the 

uterus, 114 
in salpingitis, 176 
in superinvolution of the uter- 
us, 159 
Stone in bladder, 226 
Streptococcus in endometritis, 
153 
erysipelatis causing erysipelas, 
72 
Stricture of the urethra, 215 
difficult or frequent urina- 
tion in, 216 
symptoms of, 216 
Subinvolution of uterus, 113, 157 
causes of, 157 

with prolapse of the ovaries, 
183 
Submucous fibroids of the uterus, 

130, 131 
Subserous fibroids of the uterus, 

131 
Superinvolution of the uterus, 
159 
abortion as cause of, 159 
amenorrhea in, 159 
causes of, 159 
sterility in, 159 
Subravaginal hypertrophy of the 

cervix, 167 
Syphilis differentiated from ele- 
phantiasis vulvae, 44 



Thrush of vulva, 69 

most frequent in nursing 

women, 69 
Saccharomyces albicans 

cause of, 69 
Tubal abortion, 189 

pregnancy, 187 
Tuberculosis of the endometrium 
differentiated from can- 
cer of the uterus, 142 



240 



DIAGNOSTIC INDEX. 



Tubo-ovarian mass differentiated 
from retrodisplaeement 
of the uterus, 116 
pregnancy, 188 
Tumors of the labium differenti- 
ated from hernia, 88 
of the ovaries, solid, 184 
vaginal, differentiated from 
cystocele, 83 



U 



Urethra, caruncle of the, 222 
diseases of the, 213-222 
eversion of the, 218 
pouting of the, 218 
prolapse of the, 218 
stricture of the, 215 
Urethritis, 213 
causes of, 213 
gonorrheal, 213 
symptoms of, 213 
with urethrocele, 220 
Urethrocele, 220 

as caused by pregnancy, 220 
differentiated from subure- 
thral abscess, 221 
incontinence of urine in, 220' 
with urethritis, 220 
Urination, difficult and frequent, 
in stricture of the ure- 
thra, 216 
in vesical calculus, 225 
in vesicourethral fissure, 
217 
frequency of, in cystitis, 223 
Urine, examination of, 20 
in vulvitis, 31 
in cystitis, 223 

incontinence of, in stricture of 
the urethra, 216 
in urethrocele, 220 
Uterus, cancer of the, 141 
carcinoma of the, 141 
diseases of the, 112-174 
fibroids of the, 129 ' 
fibromata of the, 129 
fibromyoma of the, 129 
inflammation of the, 146 
Inguinolabial hernia contain- 
ing, 50, 51 



Uterus — con t'd. 

inversion of the, 126 

non-gravid, 127 
metritis of the, 147 
myoma of the, 129 
myoma fibroma of the, 129 
normal position of the, 112 
polypi of the, 130 
posterior displacement of the, 

112 
prolapse of the, 122 
retroflexion of the, 115 
retroversion of the, 113 
sarcoma of the, 144 
subinvolution of the, 113, 157 
superinvolution of the, 159 



V 



Vagina, acquired stenosis and 
atresia of the, 78 
cancer of the, 98 
colpocele of the, anterior, 81 

posterior, 81 
cystocele of the, 81 
cysts of the, 97 
diseases of the, 78-111 
gonorrhea of the, 100 
hernia of the, 87 
rectocele of the, 81 
Vaginismus, 75 
causes of, 75 

lead poisoning as, 75 

masturbation as, 75 
neuralgic dvsmenorrhea with, 

75 
symptoms of, 75 
Vaginitis, 90 
chronic, 91 
diagnosis of, 91 
frequent coitus as cause of, 91 
gonorrhea as cause of, 90 
gonorrheal, 91. 104 
granular, 94 

in pregnancy, 95 

puritus vulvae with, 95 
senile, 95 

brought on by old age, 95 
septic endometritis as cause of, 

91 
simple, 90 



DIAGNOSTIC INDEX. 



241 



Vaginitis — con fd. 
symptoms of, 91 
with vulvitis, 90 
Vaginoabdominal palpation, 18 
Veins, varicose, 46 
Verruca, 59 
acuminata, 59 
vulgaris, 59 
Vesical calculus, 225 
causes of, 225 

frequent and painful urina- 
tion in, 225 
hematuria in, 225 
symptoms of, 225 
use of eystoscope in, 226 
fistula, improper repair of, 
cause of vesical calculus, 
225 
Vesicourethral fissure, 217 

difficult and frequent urina- 
tion in, 217 
symptoms of, 217 
use of urethroscope in, 217 
Vulva, chafing of the, 70 
chancre of the, 56 
chancroids of the, 52 
diseases of the, 31-77 
eczema of the, 67 



Vulva — cont'd. 

elephantiasis of the, 44 

erysipelas of the, 72 

herpes of the, 65 

kraurosis of the, 42 

pruritus of the, 39 

simple dermatitis of the, 70 

thrush of the, 69 

varicose veins of the, 46 

verrucse of the, 59 

warts of the, 59 
Vulvitis, 31 

follicular, 31 

from cancer, 32 

from diabetes, 31 

from vesicovaginal fistula, 32 

gonorrheal, 31, 32, 104 

simple, 31 

with pruritus, 31 

with vaginitis, 90 
Vulvovaginal glands, cysts of 
the, 38 



W 



Warts of the vulva, 59 
Womb, falling of the, 122 



THERAPEUTIC INDEX. 

(For Diagnostic Index see page 229.) 



Abortion, curettement for, 26 
Acetate of lead for gonorrheal 
urethritis, 215 
for kraurosis vulvae, 43 
for pruritus vulvae, 41 
of potash for acid urine in ure- 
thritis, 213 
of zinc for gonorrheal urethri- 
tis, 215 
for vulvitis, 33 
Acquired atresia of the cervix, 
171 
of the vagina, 79 
stenosis of the cervix, 172 
of the vagina, 79 
Adhesions of the clitoris, 62 
of the labia, 63 

congenital, 63, 64 
of the uterus, 118 
Adrenalin solution for hemor- 
rhage, 25 
Alcoholic stimulants in septic en- 
dometritis, 155 
Aloes for amenorrhea, 206 
Alum for prolapse of the urethra, 

219 
Amenorrhea, 206 

with acquired stenosis or atre- 
sia, 206 
Ammonia in septic endometritis, 

154 
Ammonium benzoate in cystitis, 
224 
in urethritis, 214 
Amputation of cervix for endo- 
cervicitis, 156 
for hypertrophy, 168 
for lacerations, 167 
of uterus for inversion, 128 



Anteflexion of uterus with dys- 
menorrhea, 210 
Antipyrin in chronic ovaritis, 

182 
Antiseptic solution in septic en- 
dometritis, 154 
Antistreptococcus serum for me- 
tritis, 149 
Apiol for amenorrhea, 206 
for dysmenorrhea, 211 
for superinvolution of the uter- 
us, 160 
Apomorphin for neuralgic dys- 
menorrhea, 212 
Applications, local treatment 

with, 22 
Argyrol for gonorrhea, 106 
chronic, 109 
for gonorrheal endocervicitis, 
156 
urethritis, 215 
for granular vaginitis, 95 
Aspirin for dysmenorrhea, 211 
Astringent powders for vaginitis, 

94 
Astringents for cancer of the 
uterus, 144 
for gonorrheal urethritis, 215 
for prolapse of the urethra, 

219 
for urethrocele, 221 
Atresia of the cervix, acquired, 
171 
of the vagina, acquired, 79 
Autogenous vaccines for septic 
endometritis, 155 



B 



Bartholinitis, 37 

with abscess formation, 37 



242 



THERAPEUTIC INDEX. 



243 



Bath, alkaline, for eczema of the 
vulva, 68 
sitz-, for endometritis, 153 
for herpes of the vulva, 66 
for vulvitis, 33 
Belladonna for pruritus vulvae, 
40 
tincture of, for vaginitis, 94 
for vulvitis, 33 
Benzoate of ammonium for vulvi- 
tis, 33 
of sodium for vulvitis, 33 
Benzoic acid in cystitis, 214 
Bicarbonate of soda for follicular 

vulvitis, 34 
Bichlorid of mercury solution for 
bartholinitis, 37 
for chancre, 58 
for chancroids, 55 
for chronic ovaritis, 181 
for erysipelas of the vulva, 

74 
for gonorrhea, 106, 108 
for herpes of the vulva, 66 
for pruritus vulvse, 41 
for septic endometritis, 154 
for thrush of the vulva, 70 
for vaginitis, granular, 95 

senile, 96 
for vulvitis, 33 
diabetic, 34 
gonorrheal, 34 
Bimanual replacement of uterus, 

117 
Blackwash for eczema of the 

vulva, 69 
Bladder, stone in, removal of, 

226 
Boracic acid ointment for pruri- 
tus of diabetes, 42 
solution, saturated, for vul- 
vitis, 32 
Borated talcum powder for pruri- 
tus of diabetes, 42 
Boric acid solution for cystitis, 
224 
for eczema of the vulva, 

69 
for gonorrhea, 108 
for hemorrhage, 25 
for urethritis, 214 
dusting powder for vulvitis, 33 



Braun's colpeurynter for inver- 
sion of the uterus, 128 
Bromids in chronic ovaritis, 182 

in pruritus vulvae, 40 
Bubo developing in chancroids, 

56 
Buchu, infusion of, in cystitis, 
224 
in urethritis, 214 



C 



Calamine lotion for dermatitis 

of the vulva, 71 
Calcium sulphid for elephantia- 
sis vulvae, 45 
Calculus, vesical, 226 
Calomel for erysipelas of the 

vulva, 73 
Cancer of the cervix, 144 
of the uterus, 143 

hysterectomy for, 144 
palliative treatment of, 143 
radical treatment of, 143 
of the vagina, 100 
with lacerations of the cervix, 
163 
Cannabis indica for chronic 
ovaritis, 182 
for pruritus vulvae, 41 
Carbolic acid solution for eczema 

of the vulva, 69 
Carcinoma of the cervix, 144 
of the uterus, 143 
of the vagina, 100 
Caruncle of the urethra, 222 
Cathartics for amenorrhea, 206 
for erysipelas of the vulva, 73 
for subinvolution of the uterus, 
159 
Cauterization for cancer of the 
uterus, 143 
of the vagina, 100 
for caruncle of the urethra, 

222 
for chancre, 58 
for chancroids, 54 
for verrucae, 60 
'Celiotomy for salpingitis, 177 
Cervical polypi, 170 
Cervix, acquired atresia of the, 
171 



244 



THERAPEUTIC INDEX. 



Cervix — cont'd. 

stenosis of the, 172 
amputation of, for endocer- 
vicitis, 156 
for hypertrophy, 168 
for lacerations, 167 
cancer of the, 144 
hypertrophy' of the, 168 
lacerations of the, 163 
poh^pi of the, 170 
splitting lip of. for inversion 
of the uterus, 128 
Cesarian section for pregnancy 

with fibroids, 135 
Chancre, 58 
Chancroids, 54 

bubo in, 56 
Chlorid of gold and sodium for 

chronic ovaritis, 181 
Chorioepithelioma, 174 
Citrate of potash for cystitis, 
224 
for urethritis, 214 
Cleanliness in eczema of the 
vulva, 68 
in pruritus vulvae, 40 
in vulvitis, 32 
Clitoris, adhesions of the, 62 
Cocain solution for adhesions of 
the clitoris, 62 
for chancroids, 54, 55 
for gonorrheal urethritis, 

214 
for vaginismus, 76 
Codein for dysmenorrhea, 211 

for metritis, 150 
Colpeurynter, Braun's, for inver- 
sion of the uterus, 128 
Colporrhaphy, anterior, 85 
Compresses for diseases of the 
ovaries, 179 
of glycerin and ice water for 
edema in prolapse of the 
uterus, 124 
of lead and opium for chan- 
croids, 55 
of lysol for erysipelas of the 
vulva, 74 
Constipation, 27-30 

with dysmenorrhea, 210 
with subinvolution of the uter- 
us, 159 



Constipation — cont'd. 

with superinvolution of the 
uterus, 160 
Crede's ointment for erysipelas 

of the vulva, 74 
Cresol, compound solution of, 
for gonorrheal endocer- 
vicitis, 156 
for septic endometritis, 
154 
Crossen operation for shortening 
of round ligaments, 86 
Curettement for acquired steno- 
sis of the cervix, 172 
for cancer of the uterus, 144 
for endocervicitis, 156 
for endometritis, chronic, 117 

gonorrheal, 154 
for fibroids of the uterus, 138 
for lacerations of the cervix 

with endometritis, 163 
for menorrhagia, 208 
for metritis, 150 
for miscarriage or abortion, 26 
for subinvolution of the uter- 
us, 158 
for superinvolution of the uter- 
us, 159 
Cystitis, 223 

acid urine in, 224 
alkaline urine in, 224 
Cystocele, 83 

palliative treatment of, 84 
radical treatment of, 84 
Cystotomy, suprapubic, for ves- 
ical calculus, 227 
Cysts of the Nabothian glands, 
retention, puncture for, 
25 
of the vagina, 98 
of the vulvovaginal glands, 39 
ovarian, 186 



Delayed menstruation, 204 
Depletory in chronic ovaritis, 
181 
in displacement of the uterus, 

121 
in subinvolution of the uterus, 
158 



THERAPEUTIC INDEX. 



245 



Dermatitis of the vulva, simple, 

71 
Diabetes, pruritus of, 42 
Diabetic vulvitis, 34 
Diet in cystitis, 223 

in diseases of the ovaries, 179 
in eczema of the vulva, 67 
in menorrhagia, 208 
in pruritus vulvae, 40 
in urethritis, 213 
Dilatation for acquired atresia 
of the cervix, 171 
stenosis of the cervix, 172 
for dysmenorrhea, 210 
for lacerations of the cervix, 

165 
for menorrhagia, 208 
for stricture of the urethra, 

216 
for superinvolution of the uter- 
us, 159 
for vaginismus, 76 
for vesicourethral fissure, 217 
Discharges, formaldehyd for odor 

of, 22 
Displacement of uterus, pos- 
terior, 116 
replacement of, 117 
with dysmenorrhea, 210 
Dissection of adhesions of the 
clitoris, 62 
of sac of hydrocele of labium 
majus, 49 
Diuretics in cystitis, 224 
Divulsion for acquired atresia of 
the cervix, 171 
for vesicourethral fissure, 217 
Douche, antiseptic, for acquired 
atresia of the cervix, 
172 
for carcinoma of the uterus, 

144 
for erysipelas of the vulva, 

74 
for gonorrheal endocervici- 

tis, 156 
for prolapse of the uterus, 

220 
for septic endometritis, 154 
formaldehyd, for acquired 
stenosis and atresia of 
the vagina, 81 



Douche — cont'd. 

hot, for dysmenorrhea, 210 
for menorrhagia, 208 
for vaginitis, 93 
granular, 95 
senile, 96 
local treatment with, 22 
saline, for acquired stenosis 
and atresia of the va- 
gina, 81 
for chronic ovaritis, 180 
for diseases of the ovaries, 

179 
for prolapse of the ovaries, 

183 
for subinvolution of the 
uterus, 158 
soapsuds, for replacement of 

the uterus, 119 
vaginal, for endometritis, 153 
for gonorrhea, 108 
for gonorrheal urethritis, 
214 
vulvitis, 34 
for superinvolution of the 
uterus, 159 
Dusting powder, for chancre, 58 
for chancroids, 55 
for dermatitis of the vulva, 

71 
for eczema of the vulva, 69 
for gonorrhea, 107 
for herpes of the vulva, 67 
for thrush of the vulva, 70 
for vulvitis, 33 
Dysmenorrhea, 210 
neuralgic, 211 

with anteflexion of uterus, 210 
with constipation, 210 
with displacement of uterus, 
210 



E 



Ectopic gestation, 195 

Avith hemorrhage, 195 
Eczema of the vulva, 67 
Edema in prolapse of the uterus, 

124 
Electric cautery for chancre, 58 
Electricity for superinvolution of 

the uterus, 160 



246 



THERAPEUTIC INDEX. 



Elephantiasis vulvae, 45 
chronic, 45 
hemorrhage in, 45 
Emmenagogues for amenorrhea, 

206 
Endocervicitis, 156 

gonorrheal, 156 
Endometritis, 153 
chronic, 154 

curettement for, 117 
gonorrheal, 154 
in virgins, 153 
septic, 154 

fever in, 155 
with lacerations of the cervix, 

163 
with subinvolution of the uter- 
us, 158 
Enemata for erysipelas of the 
vulva, 73 
for metritis, 150 
Ergot for amenorrhea, 206 

for menorrhagia, 208 
Erysipelas of the vulva, 73 
fever in, 73 

general treatment of, 73 
local treatment of, 174 
Excision of venereal warts, 60 
Extrauterine pregnancy, 195 



Fever in diseases of the ovaries, 
179 
in erysipelas of the vulva, 73 
in septic endometritis, 155 
Fibromata of the uterus, 138 
curettement for, 138 
hysterectomy for, 139 
intramural, 139 
myomectomy for, 139 
panhysterectomy for, 140 
with pregnancy, 135, 138 
Fissure, vesicourethral, 217 
Follicular vulvitis, 33 
Fomentations, local treatment 

with, 23 
Formaldehyd for odor of dis- 
charges, 22 
Formalin solution for hemor- 
rhage, 25 



Formula for chronic ovaritis, 
181 
for dermatitis of the vulva, 71, 

. ^^ 
for displacement of the uterus, 

121 

for dysmenorrhea, 211 

for eczema of the vulva, 69 

for gonorrhea, 107 

for pruritus vulvae, 41, 42 

for vulvitis, 34, 35 



G 



Glands, vulvovaginal, cysts of 

the, 39 
Glycerin, tamponade with, in lo- 
cal treatment, 23 
Goddard pessary for prolapse of 

the uterus, 125 
Gonococcicides for gonorrhea, 

106 
Gonorrhea, 105 
chronic, 109 
local treatment for, 26 
of vagina^ 107 
of vulva, 106 

of vulvovaginal glands, 110 
Gonorrheal endocervicitis, 156 
endometritis, 154 
urethritis, 214 
vulvitis, 34 
Goulard's solution for vulvitis, 

33 
Granular vaginitis, 95 



H 



Hamamelis for menorrhagia, 208 
Hegar's operation for cystocele 
and rectocele, 85 
uterine dilator for stricture of 
the urethra, 216 
for vesicourethral fissure, 
217 
Hemorrhage, adrenalin solution 
for, 25 
boric acid solution for, 25 
formalin solution for, 25 
in ectopic gestation, 195 
in elephantiasis vulvae, 45 



THERAPEUTIC INDEX. 



247 



Hemorrhage — confd. 
in varicose veins, 47 
tampons for checking, 25 
Hernia, inguinolabial, 51 
vaginal, 88 

reduction of, 88 
vaginolabial, 89 

treatment by abdominal 
route, 89 
by vaginal route, 89 
Herpes of the vulva, 66 
Hexamethylenamin for cystitis, 
224 
for gonorrhea, 107 
for prolapse of the urethra, 
219 
Hill, Howard, operation of peri- 
neorraphy for cure of 
rectocele, 85 
Hydrastis for menorrhagia, 208 
Hydrocele of the labium ma jus, 
49 
suppuration in, 49 
Hypertrophy of the cervix, 168 

amputation for, 168 
Hypodermoclysis in ectopic ges- 
tation, 196 
Hysterectomy for cancer of the 
uterus, 144 
for chorioepithelioma, 174 
for fibroids of the uterus, 139 
for prolapse of the uterus, 126 
for pus-tubes, 177 
supravaginal, for fibroids with 
preg-nancy, 135 



Ice bag for diseases of the 

ovaries, 179 
Ichthyol for chronic ovaritis, 181 
for subinvolution of the uterus, 

158 
tampon of, for chronic gonor- 
rhea, 109 
for displacement of uterus, 
121 
Incision for acquired atresia of 

the cervix, 171 
Inguinolabial hernia, 51 
in pregnancy, 52 
palliative treatment of^ 51 



Inguinolabial hernia — cont'd. 
radical treatment of, 52 
truss for, 51 
Injections for prolapse of the ure- 
thra, 219 
Intrauterine treatment, 26 
Intravenous transfusion in ec- 
topic gestation, 196 
Inversion of the uterus, 127 
amputation for, 128 
splitting of lip of cervix for, 

128 
technic of replacement in, 
127 
lodin, tincture of, for acute en- 
dometritis, 26 
for bubo, 56 

for cancer of the uterus, 144 
for chronic ovaritis, 181 
for gonorrhea, 109 
for hydrocele of labium ma- 
jus, 49 
for septic endometritis, 154 
for verrucae, 60 
Iodoform gauze for bartholinitis, 

37 
Iron for amenorrhea, 206 
Irrigation for cystitis, 224 
for pruritus vulvae, 41 
for vesical calculus, 227 



K 



Knee-chest position for prolapse 
of the ovaries, 184 
for replacement of the uter- 
us, 117 
Kraurosis vulvae, 43 
pruritus with^ 43 



Labia, adhesions of the, 63 
Labium majus, hydrocele of the, 

49 
Lacerations of the cervix, 163 

multiple, 164 

repair of, 164 

stellate, 167 

trachelorraphy, 165 

with cancer, 163 

with endometritis, 163 



248 



THERAPEUTIC INDEX. 



Laxatives for granular vaginitis, 

95 
Lead acetate for gonorrheal ure- 
thritis, 215 
for kraurosis vulvae, 43 
for pruritus vulvae, 41 
Leucodescent light for chan- 
croids, 55 
Litholapaxy for stone i-n bladder, 

227 
Local treatment, 21-27 
of chancre, 58 
of dysmenorrhea, 210 
of erysipelas of the vulva, 74 
of fibroids cf the uterus, 138 
of gonorrhea, 26 
of gonorrheal urethritis, 214 
of hemorrhage, 25 
of pruritus vulvae, 41 
of subinvolution of the uter- 
us, 158 
of verrucae, 60 
of vulvitis, 33 
tamponade with glycerin in, 

23 
with applications, 22 
with hot douches, 22 

fomentations, 23 
with tampons, 21, 24 
Lotions for eczema of the vulva, 
68 
for erysipelas of the vulva, 75 
Lysol solution for acquired atre- 
sia of the cervix, 171 
for chancre, 58 
for chancroids, 54, 55 
for cystitis, 224 
for diabetic vulvitis, 35 
for erysipelas of the vulva, 

74 
for gonorrheal urethritis, 

214 
for herpes of the vulva, 66 
for prolapse of the urethra, 

219 
for pyometra, 172 
for thrush of the vulva, 70 
for vaginitis, granular, 95 
senile, 96 



M 



Magnesium citrate for cystitis, 
224 
for diseases of the ovaries, 

n9 

Manganese for amenorrhea, 206 

for superinvolution of the uter- 
us, 160 
Massage for superinvolution of 

the uterus, 160 
Menopause, 201 
Menorrhagia, 208 
Menstruation, absence of, 206 

delayed, 204. 

excessive, 208 

painful, 210 

precocious, 203 
Metritis, 149 

sapremia in, 151 
Metrorrhagia, 208 
Miscarriage, curettement for, 26 
Morphin for diseases of the 
ovaries, 179 

for dysmenorrhea, 210 

for ectopic gestation, 195 

for metritis, 150 
Myomectomy for fibroids of the 
uterus, 139 



N 



Nabothian glands, retention 
cysts of the, puncture 
for, 25 
Neisser vaccines for gonorrhea, 

109 
Neuralgic dysmenorrhea, 211 
Nitric acid for chancroids, 54 
Normal salt solution for follicu- 
lar vulvitis, 33 







Oil of sandalwood for cystitis, 
224 
for gonorrhea, 107 
for urethritis, 214 
of wintergreen for gonorrhea, 
107 
for vaginitis, 94 
olive, for constipation, 30 



THERAPEUTIC INDEX. 



249 



Ointment for adhesions of the 
clitoris, 62 
for chancroids, 56 
for dermatitis of the vulva, 72 
for eczema of the vulva, 69 
for erj-^sipelas of the vulva, 74 
for pruritus vulvae, 41, 42 
for senile vaginitis, 96 
for vulvitis, diabetic, 35 

follicular, 34 
of benzoated oxid of zinc for 

vulvitis, 33 
of mercury or iodin for ele- 
phantiasis vulvae, 45 
of oleate of mercury for hy- 
drocele of the labium 
ma jus, 49 
of yellow oxid of mercury for 

kraurosis vulvae, 43 
scarlet-red, for chancroids, 56 
zinc oxid, for kraurosis vulvae, 
43 
Olive oil in constipation, 30 
Operation for cystocele, Hegar's, 
85 
for ectopic gestation, 195 
for lacerations of the cervix, 

163 
for prolapse of the urethra, 219 

of the uterus, 125 
for shortening round liga- 
ments, 121 
for vaginismus, 77 
on perineum, Howard Hill's, 
85 
Ovarian cj^sts, 186 
Ovaries, cysts of the, 186 
diseases' of the, 178 
fever in, 179 
non-puerperal, 179 
puerperal, 178 
prolapse of the, 183 
tumors of the, 185 
Ovaritis, chronic, 180 

menstrual pains in, 182 
palliative treatment of, 180 
radical treatment of, 182 
with salpingitis, 180 
Oxalic acid for amenorrhea, 206 



Panhysterectomy for fibroids of 

the uterus, 140 
Perineorrhaphy for rectocele, 85 
Peroxid of hydrogen for eczema 
of the vulva, 69 
for thrush of the vulva, 70 
Pessary for cystocele and recto- 
cele, 84 
for prolapse of the uterus, 1*25 
hard-rubber ring, for vaginal 

hernia, 88 
Skene's, for urethrocele, 221 
technic of introduction of, 120 
use of, after replacement of 
uterus, 119 
Phenacetin for dvsmenorrhea, 
211 
for metritis, 150 
Phenol for chancroids, 54 

for gonorrheal endocervicitis, 
156 
urethritis, 215 
solution for erysipelas of the 
vulva, 74 
for herpes of the vulva, 67 
for pruritus of kraurosis 
vulvae, 43 
vulvae, 41 
Pilocarpin hydrochlorate for ery- 
sipelas of the vulva, 74 
Podophyllum for constipation 
with *superinvolution of 
the uterus, 160 
Polypi, cervical, 170 
Polyvalent serum for septic en- 
dometritis, 155 
Potassuim acetate for cvstitis, 
224 
for prolapse of the urethra, 

218 
for pruritus vulvae, 40 
for vulvitis, 33 
bromid for chronic ovaritis, 
181 
for dysmenorrhea, 211 
citrate for cystitis, 224 

for urethritis, 214 
iodid for chronic ovaritis, 181 
permanganate for cystitis, 224 



250 



THEEAPEUTIG INDEX. 



Potassium permanganate — cont'd. 
for superinvolution of the 
uterus, 160 
Powders, antiseptic, for diabetic 
vulvitis, 35 
astringent, for vaginitis, 94 
Precocious menstruation, 203 
Pregnancy extrauterine, 195 
fibroids with, 135, 138 
inguinolabial hernia in, 52 
Proctoclysis in ectopic gestation, 

196 
Prolapse of the ovaries, 183 
. due to subinvolution, 183 
of the urethra, 218 
of the uterus, 124 
edema in, 124 
operations for, 125 
Protargol for gonorrhea, 106 
for gonorrheal endocervititis, 
156 
urethritis, 215 
vulvitis, 34 
for granular vaginitis, 95 
Pruritus of diabetes, 42 
from seat-worms, 42 
from skin parasites, 42 
vulvae, 40 

with kraurosis vulvae, 43 
Puerperal diseases of ovaries, 

178 
Pulsatilla, tincture of, for 
chronic ovaritis, 182 
for dysmenorrhea, 211 
Puncture of follicles in vulvitis, 
34 
of hydrocele of the labium ma- 
jus, 49 
of retention cysts of the Na- 
bothian glands, 25 
Pus-tubes, hysterectomy for, 177 
Pyometra, 172 



Quassia, infusion of, for pruri- 
tus from seat-worms, 42 
Quinin for acquiyed atresia of 
the cervix, 172 
for metritis, 150 
hydrochloric! for erysipelas of 
the vulva, 74 



R 



Rectocele, 83 

palliative treatment of, 84 
perineorrhaphy for, 85 
radical treatment of, 84 
Reduction of prolapse of the 

uterus, 124 
Replacement of uterus, 117 
bimanual, 117 
by the knee-chest position, 

in inversion, 127 

surgery for, 121 

Rest in amenorrhea, 206 

in chronic ovaritis, 180 

in cystitis, 223 

in diseases of the ovaries, 179 

in endometritis, 153 

in gonorrhea, 107 

in menorrhagia, 208 

in prolapse of the ovaries, 183 
of the urethra, 218 

in pruritus vulvae, 40 

in urethritis, 213 

in vaginitis, 93 

in vulvitis, 32 
Rochelle salts in cystitis, 224 



S 



Salol in cystitis, 224 

in urethritis, 214 
Salpingitis, 177 

with chronic ovaritis, 180 
Salt, table, in obstinate constipa- 
tion, 30 
Santal oil for cystitis, 224 
for gonorrhea, 107 
for urethritis, 214 
Sapremia in metritis, 151 
Sarcoma of the uterus, 145 
Scarlet-red ointment for chan- 
croids, 56 
Senile vaginitis, 96 
Serum, antistreptococcus, for me- 
tritis, 149 
polyvalent, for septic endome- 
tritis, 155 
Shortening round ligaments for 
prolapse of the uterus, 
126 



THERAPEUTIC INDEX. 



251 



Shortening round ligaments — 
cont'd. 

Crossen operation for, 86 
operation for, 121 
Silver nitrate solution for cysti- 
tis, 224 
for gonorrhea, 106 
for gonorrheal endocervici- 
tis, 156 
urethritis, 215 
for herpes of the vulva, 67 
for kraurosis vulvae, 43 
for prolapse of the urethra, 

219 
for vaginismus, 76 
for vaginitis, 93 
granular, 95 
senile, 96 
for vulvitis, diabetic, 35 
follicular, 34 
Sims' glass vaginal plug for 

vaginismus, 76 
Sitz-bath for endometritis, 153 
for herpes of the vulva, 66 
for vulvitis, 33 
Skene's pessary for urethrocele, 

221 
Sodium bromid for chronic ovari- 
tis, 181 
for dysmenorrhea, 211 
salicylate for dysmenorrhea, 211 
Solutions for pruritus vulvae, 42 
Stenosis of the cervix, acquired, 
172 
of the vagina, acquired, 79 
Stone in the bladder, removal of, 

226 
Strangulation of vaginolabial 

hernia, 89 
Stricture of the urethra, 216 
Strychnin for acquired atresia of 
the' cervix, 172 
for amenorrhea, 206 
for erysipelas of the vulva, 73 
for metritis, 150 
Subinvolution of the pelvic or- 
gans, 120 
of the uterus, 158 

general treatment of, 158 
local treatment of, 158 
with constipation, 159 
v^'ith endometritis, 158 



Sulphate of copper for granular 
vaginitis, 95 
of zinc for chronic ovaritis, 
181 
for gonorrheal urethritis, 

215 
for vulvitis, 33 
Superinvolution of the uterus, 
159 
with constipation, 160 
Suppositories for vaginismus, 76 
Suprapubic cystotomy for vesical 

calculus, 227 
Supravaginal hysterectomy for 
fibroids with pregnancy, 
135 



Tamponade with glycerin in lo- 
cal treatment, 23 
Tampons for checking hemor- 
rhage, 25 
for chronic gonorrhea, 109 

ovaritis, 181 . 
for cystocele and rectocele, 84 
for dysmenorrhea, 210 
for follicular vulvitis, 33 
for herpes of the vulva, 66 
for inversion of the uterus, 

128 
for menorrhagia, 208 
for prolapse of the ovaries, 
183 
of the uterus, 124 
for pruritus vulvae, 41 
for subinvolution of the pelvic 

organs, 120 
for thrush of the vulva, 70 
for vaginitis, 93 
granular, 95 
senile, 96 
local treatment with, 21, 24 
Tannic acid for prolapse of the 

urethra, 219 
Taxis in prolapse of the uterus, 

124 
Thermocautery for chancroids, 

54 
Thrush of the vulva, 70 
Thuja, tincture of, for verrucas, 
60 



252 



THEKAPEUTIC INDEX. 



Thymol solution for eczema of 

the vulva, 69 
Tincture of belladonna for vag- 
initis, 94 
for vulvitis, 33 
of chlorid of iron for erysipe- 
las of the vulva, 74 
of iodin for bubo, 56 

for cancer of the uterus, 144 
for chronic ovaritis, 181 
for endometritis, 26 
for gonorrhea, 109 
for hydrocele of labium ma- 
jus, 49 
for septic endometritis, 154 
for verrucse, 60 
of Pulsatilla for chronic ovari- 
tis, 182 
of thuja for verrucse, 60 
Tonics for acquired atresia of 
the cervix, 172 
for amenorrhea, 206 
for chronic ovaritis. 181 
for herpes of the vulva, 66 
for prolapse of the urethra, 

218 
for pruritus vulvae, 40 
for septic endometritis, 154 
for verrucae, 60 
Trachelorrhaphy for endocervici- 
tis, 156 
for lacerations of the cervix, 
165 
Transfusion, intravenous, in ec- 
topic gestation. 196 
Truss for inguinolabial hernia, 

51 
Tumors of the ovaries, 185 



U 



Urethra, caruncle of the, 222 

prolapse of the, 218 

stricture of the, 216 
Urethritis, 213 

acid urine in, 213 

alkaline urine in, 214 

gonorrheal, 214 

ulcers in, 215 

with involvement of Skene' 
glands, 215 

with urethrocele, 221 



Urethrocele, 221 
from stricture, 221 
with urethritis, 221 
Urotropin for cystitis, 224 
for gonorrhea, 107 
for prolapse of the urethra, 
219 
Uterus, adhesions of, 118 
cancer of the, 143 
fibroids of the, 138 
fibromata of the, 138 
inversion of the, 127 

amputation for, 128 
posterior displacement of the, 

116 
prolapse of the, 124 
replacement of the, 117 
bimanual, 117 

knee-chest position for, 117 
sarcoma of the, 145 
subinvolution of the, 158 
superinvolution of the, 159 



Vaccines, autogenous, for septic 
endometritis, 155 
Neisser, for gonorrhea, 109, 

110 
Wright's, for septic endometri- 
tis, 155 
Vagina, acquired stenosis and 
atresia of the, 79 
cancer of the, 100 
cystocele of the, 83 
cysts of the, 98 
gonorrhea of the, 107 
hernia of the, 88 
retocele of the, 83 
Vaginismus, 76 

forcible dilatation for, 76 
operation for, 77 
Vaginitis, 93 
granular, 95 
senile, 96 
Vaginolabial hernia, 89 
Van Horn's obstetrical catgut for 
lacerations of the cer- 
vix, 167 
Varicose veins, 47 

hemorrhage in. 47 
palliative treatment in, 47 



THERAPEUTIC INDEX. 



253 



Varicose veins — cont'd. 

radical treatment in, 47 
Vaselin for prolapse of the uter- 
us, 124 

for pruritus vulvae, 41 
Veins, varicose, 47 
Verrucse of the vulva, 60 
Vesical calculus, 226 
Vesicourethral fissure, 217 
Viburnum prunifolium for dys- 
menorrhea, 211 
for menorrhagia, 208 
Vulva, chancre of the, 58 

chancroids of the, 54 

eczema of the, 67 

elephantiasis of the, 45 

erysipelasis of the, 73 

gonorrhea of the, 106 

herpes of the, 66 

kraurosis of the, 43 

pruritus of the, 40 

simple dermatitis of the, 71 

thrush of the, 70 

varicose veins of the, 47 

verrucse of the, 60 

warts of the, 60 
Vulvitis, 32 

acid urine in, 33 

alkaline urine in, 33 

cleanliness in, 32 

diabetic, 34 

erosions in, 33 

excoriations in, 33 

follicular, 33 

gonorrheal, 34 



Vulvitis — con fd. 

rest in, 32 
Vulvovaginal glands, cysts of the, 
39 
gonorrhea of, 110 



W 



Warts of the vulva, 60 
Water, drinking of, in constipa- 
tion, 28, 29 
in pruritus vulvae, 40 
in subinvolution of the uter- 
us, 159 
in vaginitis, 94 
in vulvitis, 33 
Whiskey for dysmenorrhea, 210 
for erysipelas of the vulva, 73 
for metritis, 150 
Wintergreen, oil of, for gonor- 
rhea, 107 
for vaginitis, 94 
Wright's vaccines for septic en- 
dometritis, 155 



Zinc acetate for gonorrheal ure- 
thritis, 215 
for vulvitis, 33 
sulphate for chronic ovaritis, 
181 
for gonorrheal urethritis, 

215 
for vulvitis, 33 



II 



MAR 10 1913 



